Partners in Transition Registration : Partners in Transition : Programs : What We Do : Club 21 Learning and Resource Center

First Name

Last Name

Address

Country

Address Line 1 *

City *

State/Province *

Postal Code *

E-mail

Phone

Child Name

Child's Birthdate

Month

Day

Year

Child's Grade

What is Your Child's School Setting:

Homeschooled
General Education
Special Education
Day program
Other

Name of School and Grade:

Club 21 Member?

Regional Center:

mt4synflcfzo

Payment Information

$400 Payment in full
$50 Monthly payment
Requesting RC Funding, using SDP or applying for a scholarship

Monthly Payment Plan Agreement

I made my payment in Full.
I will set up recurring payments by clicking the box below
I will be requesting, using SDP funds, or applying for a scholarship (which is a separate form on the About Partners in Transition page).

If you are requesting Regional Center Funding or using Self Determination funds, please fill out the information bleow:

Regional Center:

Service Coordinator's Name:

Service Coordinators' Email:

INDEPENDENT FACILITATOR NAME

INDEPENDENT FACILITATOR EMAIL

FINANCIAL MANAGEMENT SERVICE (FMS)

Service Code for Invoice

According to your spending plan

UCI #

FMS Email

Credit Card Information

Cardholder Name

Credit Card #

Visa MasterCard American Express Discover

Expiration Date

Security Code

Make this a recurring payment?

No, this is a one-time payment.
Monthly

Make this a recurring payment?

Your total payment will be .

Your credit balance will cover

Your credit card will be charged

Your bank account will be charged

Partners in Transition Registration

Partners in Transition Registration

2025-2026 Partners in Transition Registration

Credit Card Information

Follow Us