2026-2027 Intervener Training Series Hold Request

A hold request must be completed for each participant.

This training is funded with a grant from the Minnesota Department of Education using federal funding, CFDA 84.027A, Special Education – Grants to States. The contents of this training do not necessarily represent the policy of the federal Department of Education, or the state Department of Education and you should not assume endorsement by the federal or state government.

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* 1. Contact Person Information

Name

Title

School District

Email Address

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* 2. Select the district's region below:

Regions 1 & 2 (Counties: Kittson, Roseau, Lake of the Woods, Marshall, Pennington, Red Lake, Beltrami, Polk, Clearwater, Norman, Mahnomen, Hubbard)

Region 3 (Counties: Koochiching, St. Louis, Itasca, Aitkin, Carlton, Lake, Cook)

Region 4 (Counties: Clay, Becker, Wilkin, Otter Trail, Traverse, Grant, Douglas, Stevens, Pope)

Regions 5 & 7 (Counties: Cass, Crow Wing, Wadena, Todd, Morrison, Mille Lacs, Kanabec, Pine, Stearns, Benton, Sherburne, Isanti, Chisago, Wright)

Regions 6 & 8 (Counties: Big Stone, Swift, Kandiyohi, McLeod, Meeker, Lac Qui Parle, Yellow Medicine, Renville, Lincoln, Lyon, Redwood, Pipestone, Murray, Cottonwood, Rock, Nobles, Jackson)

Region 9 (Counties: Sibley, Nicollet, LeSueur, Brown, Watonman, Blue Earth, Waseca, Martin, Faribault)

Region 10 (Counties: Rice, Goodhue, Wabasha, Steele, Dodge, Olmsted, Winona, Freeborn, Mower, Fillmore, Houston)

Region 11 (Metro Area: Anoka, Hennepin, Carver, Scott, Dakota, Ramsey, Washington)

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* 3. Responsible Party Information

(The responsible party is the person who approves the intervener training invoice for payment, often the special education director.)

Name

Title

Email Address

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* 4. If your participant is traveling from outside of the metro area, the MN DeafBlind Project grant pays for a double occupancy hotel room. However, many participants request a single room. If this is the case, the MNDBP can cover half of the cost which is approximately $70-$75 per night. Please provide input below if your district or Regional Low Incidence Facilitator (RLIF) will provide financial support for this.

The district will pay the other half of a single occupancy room.

The Regional Low Incidence Facilitator (RLIF) will use regional funds to pay for the other half of a single occupancy room.

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* 5. DeafBlind Student Information

First and Last Name

Date of Birth

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* 6. Has the DeafBlind student already been counted in the national child count completed by the teacher of blind/visually impaired and/or teacher of deaf/hard of hearing?

If not, have your teacher of blind/visually impaired and teacher of deaf/hard of hearing complete the form. See the link:

Link to current Federal Child Count Form: MN DeafBlind Project Federal Census - 2026-2027

Yes

Additional Comments

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* 7. Has an intervener been hired for this student yet?

Yes

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* 8. If you have hired an intervener, what is the intervener's name and email address?
Note: We will send a registration link directly to participants in September to complete the registration process.

Intervener Name

Email Address

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* 9. If you have not yet hired an intervener, when do you hope to fill the position?

Before the school year starts.

By the end of September.

Before the first weekend of intervener training at the end of October.

Team Information for Support:

Since the intervener does not work in isolation, but within the context of a team, and works under the direction of licensed educators and related service providers, please provide team member's names and email addresses, so that we can send them the same resources and recap email that interveners receive after each weekend.

This strengthens the team's provision of services for the DeafBlind student and for the intervener to provide access, so that more people on the team understand deafblindness.

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* 10. Please provide the DeafBlind student's team members' names and email addresses

If you do not yet know the team members' names and email addresses at the time that you complete this form, we will reach out to you early fall or after the form has been submitted.

IEP Manager Name and Email Address

Special Education Teacher and Email Address

Teacher of Blind/Visually Impaired and Email Address

Teacher of Deaf/Hard of Hearing and Email Address

Speech-Language Pathologist and Email Address

Other Related Service Providers and Email Addresses (if known)

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100% of survey complete.

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* 1. Contact Person Information

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* 2. Select the district's region below:

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* 3. Responsible Party Information (The responsible party is the person who approves the intervener training invoice for payment, often the special education director.)

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* 5. DeafBlind Student Information

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* 7. Has an intervener been hired for this student yet?

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* 8. If you have hired an intervener, what is the intervener's name and email address?Note: We will send a registration link directly to participants in September to complete the registration process.

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* 9. If you have not yet hired an intervener, when do you hope to fill the position?

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* 10. Please provide the DeafBlind student's team members' names and email addressesIf you do not yet know the team members' names and email addresses at the time that you complete this form, we will reach out to you early fall or after the form has been submitted.

* 3. Responsible Party Information

(The responsible party is the person who approves the intervener training invoice for payment, often the special education director.)

* 8. If you have hired an intervener, what is the intervener's name and email address?
Note: We will send a registration link directly to participants in September to complete the registration process.

* 10. Please provide the DeafBlind student's team members' names and email addresses

If you do not yet know the team members' names and email addresses at the time that you complete this form, we will reach out to you early fall or after the form has been submitted.