1. 2019-20 Affiliation Form

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* 1. YOUR FULL NAME:

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* 2. YOUR PREFERRED NAME:

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* 3. YOUR OFFICIAL SCHOOL NAME:

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* 4. YOUR SCHOOL SYSTEM NAME:

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* 5. Are you receiving a Support Grant/Extended Day from: (Please check one of the following)

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* 6. Are you Receiving...

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* 7. Complete School Address:

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* 8. School Phone Number (Area Code and Extension if Applicable)

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* 9. Your Cell Phone Number

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* 10. Your Email Address:

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* 11. What is the total number of students with disabilities enrolled in CTAE courses at your high school (This is an overall total number and DOES NOT reflect only students with CTI listed in their in IEP)

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* 12. What is the total number of students with disabilities at your high school with CTI services listed in their IEP?

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* 13. How many 9th Grade CTI Males?

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* 14. How many 9th Grade CTI Females?

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* 15. How many 10th Grade Males?

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* 16. How many 10th Grade Females?

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* 17. How many 11th Grade Males?

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* 18. How many 11th Grade Females?

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* 19. How many 12th Grade Males?

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* 20. How many 12th Grade Females?

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* 21. Total Number of Male CTI Students? (9th-12th)

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* 22. Total Number of Female CTI Students? (9th-12th)

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* 23. Please indicate the anticipated number of students attending FALL RALLY October 9, 2019?

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* 24. Please indicate the anticipated number of students attending another CTSO Rally Day at the Fair? (Please list number and name of CTSO Day)

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* 25. Please indicate the anticipated number of students attending Fall Conference on November 21-22, 2019?

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* 26. Please indicate the anticipated number of students attending State Conference on April 14-16, 2020?

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* 27. What will be your main funding source for student participation in CTI?

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* 28. Please list your Principal's Name and email address:

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* 29. Please list your Special Education Director's Name and Email address:

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* 30. Please list your CTAE Director's Name and Email address:

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* 31. Please list your CTAE Supervisor's Name and Email address:

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* 32. Please list your VR Field Counselor's Name and Email address:

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* 33. Have you planned a meeting with each of the above-listed names to discuss your program, responsibilities, student activities, budget, fundraising, etc?

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* 34. Please check all CTSOs available at your school for student membership

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* 35. Reminder:  After submitting this survey, you still must remember that to be officially affiliated with Georgia CTI and receive recognition, you will send your $75 affiliation fee to Georgia CTI 3 Central Plaza Ste 245, Rome, GA 30161 by September 15, 2019. If needed, an Invoice is located online at www.georgiacti.org, coordinator resource page. Any Questions? Contact Mary Donahue!

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* 36. By inserting my full name below, I certify that the information provided in this survey is of students with disabilities that I am serving in the CTI Program at my high school.

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