Educational Partnership Registration

2024-2025 Educational Partnership Parent Registration

Please choose Program Option Below:

Option 1- Core Program
Option 2- Home School/Alternative School Cohort

Parent Name

E-mail

Phone

Address

Country

Address Line 1 *

City *

State/Province *

Postal Code *

Child Name

Birthdate of Child

Grade 2024-2025

School

School District

Educator Name

Educator Email

Educator's Position (Gen Ed teacher, Para, Aide, etc)

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.

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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

Make this a monthly payment?

Yes, charge me today and on the 6th 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 Registration

Educational Partnership Registration

2024-2025 Educational Partnership Parent Registration

Credit Card Information

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