Educational Partnership Registration

2023-2024 Educational Partnership Parent Registration

Parent Name

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E-mail

Phone

Address

City

Zip Code

Child Name

Birthdate of Child

Grade 2023-2024

School

School District

Teacher Name

Teacher Email

Administrator's Name

Administrator's Email

Have you previously attended the Educational Partnership Program?

Club 21 Member?

Yes
No
Unsure (Club 21 membership must be renewed every January)

Agreement

$400(Partnership & Pathway fee, covers cost of one teacher)
$100 Deposit + 3 recurring payments. *Click the recurring payment box in the credit card information section
Asking Regional Center to Fund/using Self Determination Funds or applying for a scholarship (which is a separate form on the About Educational Partnerships page)

All parent participants MUST be a Club 21 member.

Regional Center:

Regional Center (RC) Coordinator's Name:

RC Coordinator's Email:

RC Coordinator's Phone:

Independent Facilitator name

Independent Facilitator email

Financial Management Service (FMS)

Service Code for Invoice

According to your spending plan

FMS email

Payment Option

Pay Now
Pay Later

Credit Card Information

Cardholder Name

Credit Card #

Expiration Date

Security Code

Billing Zip Code

Make this a monthly payment?

Yes, charge me today and on the 19th of every following month.

Make this a monthly payment?

Your total payment will be

Your credit balance will cover

Your credit card will be charged

Your bank account will be charged

Educational Partnerships

Educational Partnership Registration

Educational Partnerships Registration

2023-2024 Educational Partnership Parent Registration

Credit Card Information