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.
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