EXIT 2020-2021 Georgia CTI Affiliation Form 1. 2020-21 Affiliation Form Question Title * 1. YOUR FULL NAME: OK Question Title * 2. YOUR PREFERRED NAME: OK Question Title * 3. YOUR OFFICIAL SCHOOL NAME: OK Question Title * 4. YOUR SCHOOL SYSTEM NAME: OK Question Title * 5. Are you receiving a Support Grant/Extended Day from: (Please check one of the following) State Department Special Education None Other (please specify) OK Question Title * 6. Are you Receiving... 10 Hours 20 Hours Extended Year Other (please specify) OK Question Title * 7. Complete School Address: OK Question Title * 8. School Phone Number (Area Code and Extension if Applicable) OK Question Title * 9. Your Cell Phone Number OK Question Title * 10. Your Email Address: OK Question Title * 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) OK Question Title * 12. What is the total number of students with disabilities at your high school with CTI services listed in their IEP? OK Question Title * 13. How many 9th Grade CTI Males? OK Question Title * 14. How many 9th Grade CTI Females? OK Question Title * 15. How many 10th Grade Males? OK Question Title * 16. How many 10th Grade Females? OK Question Title * 17. How many 11th Grade Males? OK Question Title * 18. How many 11th Grade Females? OK Question Title * 19. How many 12th Grade Males? OK Question Title * 20. How many 12th Grade Females? OK Question Title * 21. Total Number of Male CTI Students? (9th-12th) OK Question Title * 22. Total Number of Female CTI Students? (9th-12th) OK Question Title * 23. Please indicate the anticipated number of students attending FALL Employability Summit? ($300 per school to participate) OK Question Title * 24. If happening, Please indicate the anticipated number of students attending a CTSO Rally Day at the Fair? (Please list number and name of CTSO Day) OK Question Title * 25. Please indicate the anticipated number of students attending Spring State Career Portfolio and Competition Conference? ($50 per student to participate) OK Question Title * 26. What will be your main funding source for student participation in CTI? OK Question Title * 27. Please list your Principal's Name OK Question Title * 28. Please list your Principal's email address: OK Question Title * 29. Please list your Special Education Director's Name OK Question Title * 30. Please list your Special Education Director's Email address: OK Question Title * 31. Please list your CTAE Director's Name OK Question Title * 32. Please list your CTAE Director's Email address: OK Question Title * 33. Please list your VR Field Counselor's Name OK Question Title * 34. Please list your VR Field Counselor's Email address: OK Question Title * 35. Please list your local senator's name (https://openstates.org/find_your_legislator/): OK Question Title * 36. Please list your local representative's name (https://openstates.org/find_your_legislator/): OK Question Title * 37. Have you planned a meeting with each of the above-listed names (except senator/representative) to discuss your program, responsibilities, student activities, budget, fundraising, etc? Yes No OK Question Title * 38. Please check all CTSOs available at your school for student membership DECA FBLA FCCLA FFA FIRST ROBOTICS HOSA SKILLSUSA TSA OK Question Title * 39. 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, 2020. If needed, an Invoice is located online at www.georgiacti.org, coordinator resource page. Any Questions? Contact Mary Donahue! I understand that the $75 must be sent to Georgia CTI State Headquarters by September 15, 2020 to be officially recognized as a Georgia CTI 2020-21 Affiliate! Other (please specify) OK Question Title * 40. 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. OK DONE