This form is for 21st Century Community Learning Center (CCLC) State Education Agency (SEA) Coordinators who wish to request free technical assistance from the 21st CCLC’s contracted Y4Y training team. All requests must be received at least eight weeks in advance to allow adequate time for official review and approval. Approval is required before technical assistance can be scheduled and delivered.

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* 1. State:

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* 2. SEA Coordinator/ SEA primary contact name

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* 3. Email:

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* 4. Phone number:

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* 5. Requested training date(s). Please request 8 weeks in advance.

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* 6. What type of technical assistance event are you requesting?

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* 7. Anticipated audience size

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* 8. Indicate the audience for technical assistance. Select all that apply:

Note: All participants will be expected to create a free Y4Y account as part of the requested technical assistance. On-site technical assistance events must be a minimum of 4 training hours.

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* 9. Please select the professional learning objectives most pertinent to the technical assistance you are requesting. 

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* 10. Based on your desired learning objectives, please rank the Y4Y technical assistance topics, with 1 being your top choice:

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* 11. How did you determine the Y4Y technical assistance requested meets the professional learning needs of your sub-grantees? (For example, is this request based on State Priority, National Priority, Evaluation Results, Needs Assessment Results, Federal Suggestion from monitoring and/or technical assistance visit, etc.? Please provide as much detail as possible.)

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* 12. Please attach or upload any files relevant to this request.

DOCX, DOC, JPEG, GIF, JPG, PDF, PNG file types only.
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* 13. Would you like to include an overview of Y4Y in your technical assistance event? Y4Y recommends including an overview session for on-site events, especially at conferences.

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* 14. If requesting on-site technical assistance, please indicate the type of event:

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* 15. By when do you need to know whether your request is approved?

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* 16. Please share any additional information relevant to your request (e.g. number of participants to receive Y4Y technical assistance, number of desired sessions, length of sessions, etc.):

You will receive confirmation of receipt of your request from y4yta@seiservices.com within one business day.

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