Jumpstart Regulation Course- CLTS funding request

Please note that due to the administrative time involved in accepting CLTS funding, we ask that only those that are fully committed to joining this group complete this form.

In order to expedite this process, we will request 1 unit of "unpaid caregiver training" for $300 for this group from your case manager with a start date of June 23rd!

Child's First Name

Child's Last Name

Parent's First Name

Parent's Last Name

Phone

Email

CLTS Case manager full name and e-mail (please note, failure to provide full information may affect a place in the group)

Preferred class time

12:00 pm Thursdays

12:00 Tuesdays

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Jumpstart Regulation Course- CLTS funding request