<p> 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]</p><p>DUE DATE: October 1, 2015 Official Membership Application Please note: One form per Coordinator is required (One $45 Affiliation Fee per school) </p><p>Official School Name: ______</p><p>Date Chartered: Region: ______School System: ______10/01/15 </p><p>CTI Coordinator Name: ______</p><p>Are You Receiving a Support Grant/Extended Day from: (Please check one of the following)</p><p>State Department ______Special Education ______Other ______None______</p><p>Are you receiving: 10 Hours 20 Hours Extended Year Yes______No ______</p><p>Complete School Address: </p><p>School Phone (Please include Area Code and Extension if applicable): ______</p><p>Coordinators Home Number: ______</p><p>Coordinators Cell Number: ______</p><p>Coordinator’s Email Address: ______</p><p>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.</p><p>Gender 9th grade students 10th grade students 11th grade students 12th grade students TOTAL</p><p>Male</p><p>Female List the total number of students served for the following CTAE Pathways</p><p>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</p><p>*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)</p><p>Lab or Classroom</p><p>CTI Parents Involved with your program</p><p>Total Number: </p><p>Advisory Council Members</p><p>Total Number: </p><p>Other classes taught: </p><p>1.______2.______</p><p>3. ______4. ______</p><p>Other responsibilities: ______(Examples: Co-Sponsor, Coach, Department Chair, Transition Specialist, etc.)</p><p>What will be your main funding source for student participation in CTI: ______</p><p>Please list the following personnel at your local school and system:</p><p>Principal: ______</p><p>CTAE Director: ______</p><p>CTAE School Supervisor: ______</p><p>Special Education Director: ______</p><p>Have you planned a meeting with the above individuals to discuss your responsibilities, student activities, budget, fundraising, etc.? Circle One: YES or NO</p><p>Please check the following CTSOs available at your school for student membership:</p><p>FCCLA HOSA DECA FBLA </p><p>FFA TSA SkillsUSA </p><p>I certify that the information provided is of students with disabilities that I am serving in the CTI program for my school :</p><p>Coordinators Signature: ______Date: ______</p><p>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:</p><p>All applications and fees must be postmarked by October 1, 2015 . Retain a copy for your records. </p><p>3 FOR OFFICE USE ONLY: Check # ______Amount: ______</p><p>Date: ______Received From: ______</p>