DUE DATE: October 1, 2015 Official Membership Application

Georgia Career and Technical Instruction Mary Davis Donahue 3 Central Plaza, Ste 245 Rome, Georgia 30161 Office 678-617-0439 Fax 706.314.9624 [email protected]

DUE DATE: October 1, 2015 Official Membership Application Please note: One form per Coordinator is required (One $45 Affiliation Fee per school)

Official School Name: ______

Date Chartered: Region: ______School System: ______10/01/15

CTI Coordinator Name: ______

Are You Receiving a Support Grant/Extended Day from: (Please check one of the following)

State Department ______Special Education ______Other ______None______

Are you receiving: 10 Hours 20 Hours Extended Year Yes______No ______

Complete School Address:

School Phone (Please include Area Code and Extension if applicable): ______

Coordinators Home Number: ______

Coordinators Cell Number: ______

Coordinator’s Email Address: ______

Membership Summary Please indicate number of participants in each of the categories listed below. This information is for the first semester of the 2015-2016 school year.

Gender 9th grade students 10th grade students 11th grade students 12th grade students TOTAL

Female List the total number of students served for the following CTAE Pathways

CTI Student CTI Student CTAE Pathways (Alpha Order) Participation CTAE Pathways (Alpha Order) Participation Administrative/Informatio Graphic Design n Support Agribusiness Health Informatics Management Homeland Security & Emergency Services Agricultural Mechanics Interactive Media Agriscience Interior Design Aircraft Support JROTC – Air Force, Animal Science Army, Marine Corps, Architectural Drawing & Navy Design Law & Justice Biotechnology Research & Development Manufacturing Broadcast/Video Marine Engine Production Technology Climate Control Systems Marketing & Technology (HVACR) Management Marketing Collision Repair Communications & Computer Networking Promotion Computer Systems and Metals Technology Support Nutrition & Food Science Computing Personal Care Services – Construction Cosmetology Consumer Services Physical Medicine CTAE Related Advanced Plant Science/Horticulture Courses Small Business Culinary Arts Development Diagnostic Services Sports & Entertainment Early Childhood Marketing Education Teaching as a Profession Electronics Therapeutic Services – Emergency Services Energy Systems Therapeutic Services – Engineering Medical Services Engineering Graphics & Therapeutic Services – Design Nursing Fashion Marketing Transport Logistical Financial Management – Operations Accounting (Ground/Marine) Financial Management – Transport Logistical Services Support (Ground/Marine) Flight Operations Travel Marketing & Forestry/Natural Lodging Management Resources Veterinary Science

*Total for Pathway Numbers:______*This number may differ from your total caseload or FTE numbers as students may be enrolled in several pathways. 2 Intervention Program Students - CTI Model used (circle one)

Lab or Classroom

CTI Parents Involved with your program

Total Number:

Advisory Council Members

Total Number:

Other classes taught:

1.______2.______

3. ______4. ______

Other responsibilities: ______(Examples: Co-Sponsor, Coach, Department Chair, Transition Specialist, etc.)

What will be your main funding source for student participation in CTI: ______

Please list the following personnel at your local school and system:

Principal: ______

CTAE Director: ______

CTAE School Supervisor: ______

Special Education Director: ______

Have you planned a meeting with the above individuals to discuss your responsibilities, student activities, budget, fundraising, etc.? Circle One: YES or NO

Please check the following CTSOs available at your school for student membership:

FCCLA HOSA DECA FBLA

FFA TSA SkillsUSA

I certify that the information provided is of students with disabilities that I am serving in the CTI program for my school :

Coordinators Signature: ______Date: ______

Instructions: Mail a copy of the application along with a check for your fees of $45 to 3 Central Plaza, Ste 245; Rome, Georgia 30161. Make checks payable to Georgia CTI:

All applications and fees must be postmarked by October 1, 2015 . Retain a copy for your records.

3 FOR OFFICE USE ONLY: Check # ______Amount: ______

Date: ______Received From: ______