Club 21 Learning and Resource Center : What We Do : Self Determination Training Registration

Self Determination Training Registration

Below is the registration for the Fall 2021 session of the Self Determination workshop.

Registrants will meet on September 26, October 3, October 10, October 17, and October 24 from 3:30pm-5:30pm virtually. If you have any questions, please email programs@clubtwentyone.org.

Apply for a scholarship here.

First Name (Required)

Last Name (Required)

Address

Country

Address Line 1 *

City *

State/Province *

Postal Code *

E-mail (Required)

Phone (Required)

Child Name (Required)

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Child's Birthdate

Child's Grade (Required)

What is Your Child's School Setting:

Homeschooled
General Education
Special Education
Day program
Other

Club 21 Member? (Required)

This training is a perk of Club 21 Membership. Please confirm your membership.

Please select your payment option below.

Payment in full $100
$50 down payment + $50 next month (be sure to select monthly payment in the credit card information section below)
I will be applying for a scholarship (which is a separate application)

Credit Card Information

Cardholder Name (Required)

Credit Card # (Required)

Visa MasterCard American Express Discover

Expiration Date (Required)

Security Code (Required)

Visa®, MasterCard® & Discover® cardholders
Your security code is the 3-digit code at the end of the signature field on your card's back.

American Express® cardholders
Your security code is the 4-digit code located above the actual credit card number on your card's front.

Make this a monthly payment?

Yes, bill my card today and on the 26th 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