2024-2025 Intervener Training Series Hold Request

A hold request must be completed for each participant.

Funding for this training is made possible with a grant from the MN Department of Education. The sources of the funds are: Federal award Special Education – Programs to States, CFDA 84.027A Special Education. And federal award – Project Title: Technical Assistance and Dissemination to Improve Services and Results for Children with Disabilities CFDA 84.326T of P.L. 108-446 Individuals with Disabilities Act.

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* 1. Contact Person Information

Name

Title

School District

Email Address

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* 2. Select the district's region below:

Regions 1 & 2 (Counties: Kittson, Roseau, Lake of the Woods, Marshall, Pennington, Red Lake, Beltrami, Polk, Clearwater, Norman, Mahnomen, Hubbard)

Region 3 (Counties: Koochiching, St. Louis, Itasca, Aitkin, Carlton, Lake, Cook)

Region 4 (Counties: Clay, Becker, Wilkin, Otter Trail, Traverse, Grant, Douglas, Stevens, Pope)

Regions 5 & 7 (Counties: Cass, Crow Wing, Wadena, Todd, Morrison, Mille Lacs, Kanabec, Pine, Stearns, Benton, Sherburne, Isanti, Chisago, Wright)

Regions 6 & 8 (Counties: Big Stone, Swift, Kandiyohi, McLeod, Meeker, Lac Qui Parle, Yellow Medicine, Renville, Lincoln, Lyon, Redwood, Pipestone, Murray, Cottonwood, Rock, Nobles, Jackson)

Region 9 (Counties: Sibley, Nicollet, LeSueur, Brown, Watonman, Blue Earth, Waseca, Martin, Faribault)

Region 10 (Counties: Rice, Goodhue, Wabasha, Steele, Dodge, Olmsted, Winona, Freeborn, Mower, Fillmore, Houston)

Region 11 (Metro Area: Anoka, Hennepin, Carver, Scott, Dakota, Ramsey, Washington)

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* 3. Responsible Party Information

(The responsible party is the person who approves the intervener training invoice for payment, often the special education director.)

Name

Title

Email Address

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* 4. Only for participants traveling from outside of the metro area, please indicate support for a single occupancy hotel room (The MN DeafBlind Project grant pays for a double occupancy room. Some participants request a single occupancy hotel room, so we need your input.)

The district will pay the other half of a single occupancy room.

The Regional Low Incidence Facilitator (RLIF) will use regional funds to pay for the other half of a single occupancy room.

The participant will pay the other half of a single occupancy room.

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* 5. DeafBlind Student Information

First and Last Name

Date of Birth

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* 6. Has the DeafBlind student already been counted in the national child count completed by the teacher of blind/visually impaired and/or teacher of deaf/hard of hearing in March 2024?

If not, have your teacher of blind/visually impaired and teacher of deaf/hard of hearing complete the form. See the link:

Link to current Federal Child Count Form: https://SBC.formstack.com/forms/mn_deafblind_project_federal_census2023

Yes

Additional Comments

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* 7. Has an intervener been hired for this student yet?

Yes

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* 8. If you have hired an intervener, what is the intervener's name and email address?
Note: We will send a registration link directly to participants in September to complete the registration process.

Intervener Name

Email Address

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* 9. If you have not yet hired an intervener, when do you hope to fill the position?

Before the school year starts.

By the end of September.

Before the first weekend of intervener training at the end of October.

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100% of survey complete.

Question Title

* 1. Contact Person Information

Question Title

* 2. Select the district's region below:

Question Title

* 3. Responsible Party Information (The responsible party is the person who approves the intervener training invoice for payment, often the special education director.)

Question Title

* 4. Only for participants traveling from outside of the metro area, please indicate support for a single occupancy hotel room (The MN DeafBlind Project grant pays for a double occupancy room. Some participants request a single occupancy hotel room, so we need your input.)

Question Title

* 5. DeafBlind Student Information

Question Title

Question Title

* 7. Has an intervener been hired for this student yet?

Question Title

* 8. If you have hired an intervener, what is the intervener's name and email address?Note: We will send a registration link directly to participants in September to complete the registration process.

Question Title

* 9. If you have not yet hired an intervener, when do you hope to fill the position?

* 3. Responsible Party Information

(The responsible party is the person who approves the intervener training invoice for payment, often the special education director.)

* 8. If you have hired an intervener, what is the intervener's name and email address?
Note: We will send a registration link directly to participants in September to complete the registration process.