2019-2020 Fall Baby LEADers Application

Families will be informed that they've been accepted by October 4, 2019.

Complete this application only if you are able to attend ALL training sessions.

Training dates are:

October 12, 2019

October 26, 2019

November 9, 2019

November 23, 2019

All training times are from 9:00am to 1:00pm and will be held at Frostburg State University, 60 W. Washington St, Hagerstown, MD 21740

If you need any assistance completing the application or have any questions, email Mai Hall at mai@ppmd.org.

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* 1. Please provide your contact information.

First Name: *

Last Name: *

Address: *

Address 2:

City/Town: *

State: *

ZIP: *

Email Address: *

Phone Number: *

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* 2. Are you able to commit to ALL required training activities?

Yes

Comment

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* 3. In what county of Maryland do you live?

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* 4. Are you Hispanic?

Yes

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* 5. What is your race?

White

Black or African-American

American Indian or Alaskan Native

Asian

Native Hawaiian or other Pacific Islander

Multiple races

Other (please specify)

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* 6. Please tell us about your child(ren) with a disability.

	Age	Disability
Child 1	Child 1 Age menu	Child 1 Disability menu
Child 2	Child 2 Age menu	Child 2 Disability menu
Child 3	Child 3 Age menu	Child 3 Disability menu
Child 4	Child 4 Age menu	Child 4 Disability menu

Other (please specify)

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* 7. Where does your child attend school?

Public school

Non-public school (paid by the school system)

Private school (paid by the family)

Maryland School for the Deaf

Home schooled

Other (please specify)

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* 8. Does your child have 504, IEP, or IFSP?

504

IEP

IFSP

Other (please specify)

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* 9. Tell us your experience with the Early Intervention process so far.

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* 10. Tell us why you should be chosen to participate in Baby LEADers.

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* 11. How will you use the information learned in this training?

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* 12. Do you need a sign language interpreter?

Yes

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* 13. Do you have any other language needs (i.e. French, Chinese, Mandarin, Large Print, etc.)

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* 14. ACCOMMODATIONS: Please tell us any accommodations that you require (including dietary). Please note that we will try to make reasonable accommodations but you may need to consider bringing food you are confident will meet your needs.

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* 1. Please provide your contact information.

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* 2. Are you able to commit to ALL required training activities?

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* 3. In what county of Maryland do you live?

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* 4. Are you Hispanic?

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* 5. What is your race?

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* 6. Please tell us about your child(ren) with a disability.

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* 7. Where does your child attend school?

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* 8. Does your child have 504, IEP, or IFSP?

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* 9. Tell us your experience with the Early Intervention process so far.

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* 10. Tell us why you should be chosen to participate in Baby LEADers.

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* 11. How will you use the information learned in this training?

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* 12. Do you need a sign language interpreter?

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* 13. Do you have any other language needs (i.e. French, Chinese, Mandarin, Large Print, etc.)

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* 14. ACCOMMODATIONS: Please tell us any accommodations that you require (including dietary). Please note that we will try to make reasonable accommodations but you may need to consider bringing food you are confident will meet your needs.

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* 15. Do you need child care? Please list how many and their ages.