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Request for Financial Assistance

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- We will review your information for consideration of Financial Aid for your Conscious Discipline training request. We make our best effort to accommodate as many requests as we can, but cannot guarantee the award of any financial assistance.
- After review and verification of your request, you will receive a written response via email with information regarding the outcome of your request.
- Please allow us up to two weeks to review and consider your request.
- If you have any questions or need further assistance, contact us at 800-842-2846..
Please check to proceed.*
- I have read and accept the terms above.

Contact Information
Name*
First Last
Organization Name
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Emergency Cell*
Email*

Billing Contact Information
Name of Person to Receive Invoice*
First Last
Organization
Billing Address*
Same as Contact Information

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email to Send Invoice*
Email of Secretary
Phone of Payer*

Training Information
Request Speaker*
Proposed Date*
MM slash DD slash YYYY
Speaking Site
Site Address*
Same as Contact Information

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Describe the Event
Type of Audience*
Please select all that apply
- Early Head Start Administration
- 0-3 Infant/Toddler Early Head Start Teachers
- Head Start Administration
- Head Start Teachers
- Childcare Administrators
- 3-5 Year Olds Preschool/Childcare Teachers
- Elementary School Administration
- 4-6 Elementary Teachers
- PreK/K Teachers
- Elementary School Teachers
- Middle School/High Schools
- Art/Music/Specialists Teachers
- Before/After School Care
- Tribal Schools/Communities
- Special Needs
- Behavior Interventionist
- Mental Health Professionals
- Foster Care Organizations/Non-Profit Organizations
- Faith Based
- Bilingual/Spanish
- Parents
- Other Not Listed
Please describe
Age Group of Children*
Please select all that apply
- Pre-K/K
- Elementary
- Jr. High
- High School
Estimated Number in Attendance*
Start Time*

: Hours

Minutes

AM/PM
End Time*

: Hours

Minutes

AM/PM
Time Zone*
Approximate distance from site to airport (in miles)

Additional Information
Have you had Conscious Discipline training before?*
- Yes
- No
Certified Instructors
- Any Conscious Discipline Certified Instructors within the area may attend and participate by observation at this training.
How did you hear about us?
Amount of funding available for event
Any additional information that we should know?

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648 Trestle Pt
Sanford, FL 32771

407-366-0233 Contact Us

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