Parent Leadership Training Institute
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Middlesex County Parent Leadership Training Institute Application Form To Apply Type or print clearly & send to Parent Leadership Training Institute, 310 Hunting Hill Ave, Middletown, Connecticut 06457. Call Rebecca Deotte, Coordinator (860) 638-1463 if you have questions. Thank you. Please note that all classes will be conducted in English ._________________________________________ First Name Middle Name Last Name __________________________________________ Widowed Divorce Other _________ Child Care I will use child care at the class Address I will NOT need child care. I will use child care at home __________________________________________ __________________________________________ City State/Province Zip Transportation I will need help with transportation I will NOT need help with transportation Home Phone Gender Work Phone Direct line extension __________________________________________ Email Background Information Number of Children _____ Ages ___________ Other Adults in Household Yes Family Status Single No Married female Race/Ethnic Background White __________________________________________ Fax male Black/African American Asian/Pacific Islander Hispanic Other_____________________________ Page 2 What issues concern you for your children and others? What skills would you like to learn to become a strong parent leader? Applicant’s Signature: ________________________ Date: ___________ How did you hear about PLTI? _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ Parent Leadership Training Institute, 310 Hunting Hill Ave, Middletown, Connecticut 06457 or email to plti@mpsct.org. Return to:
