Special Needs Training & Technical Assistance Request

Special Needs Training & Technical Assistance Request Form

Request a Training under the Special Needs Training & Technical Grant for Providers who Care for Infants and Toddlers. We will check availability for the desired date. A representative of Project ACT will be in touch with you.

Does your center of association care for any children between the ages of Birth to 3 years old? * Required
Name * Required
First Last
Name of Organization * Required
County of Organization * Required
Address of Organization * Required
Street Address Address Line 2 City State ZIP Code
Phone * Required
Email * Required
How did you hear about this training opportunity? * Required
- Project ACT's Website
- Facebook
- Project ACT Staff Person
- Tuesday Tidbits
- Word of Mouth
- Other
Training Date * Required
MM slash DD slash YYYY
Training Time * Required

: Hours

Minutes

AM/PM AM/PM
Training Title * Required
Number of Expected Participants
Please enter a number greater than or equal to 15.
There is a minimum of 10 participants needed.
Training Location
Street Address Address Line 2 City State ZIP Code

Please give training location if address differs from previous address given
Technical Assistance (Mentoring & Coaching Sessions)
Training specific mentoring and coaching sessions are provided. 25% of training attendees are expected to participating in both mentoring and coaching sessions. Participants receive 2 additional core of knowledge hours by participating in the mentoring and coaching sessions. (only provided to participants who have attended the training, required to attend both sessions to receive COK credit)
Number of Expected Participants
Mentoring & Coaching Sessions
1st Technical Assistance Date * Required
MM slash DD slash YYYY

Cannot be provided until two weeks following the training
1st Technical Assistance Time * Required

: Hours

Minutes

AM/PM AM/PM
2nd Technical Assistance Date * Required
MM slash DD slash YYYY

Cannot be provided until two weeks following the 1st Technical Assistance date
2nd Technical Assistance Time * Required

: Hours

Minutes

AM/PM AM/PM

54799

Special Needs Training & Technical Assistance Request Form

Technical Assistance (Mentoring & Coaching Sessions)