Born to Learn™ Institute Prenatal to 3 Years
Registration Form for Supervisors (SUP)
Home Address Phone
Program Name Position / Title
Office Address Office Phone
Type of Supervisor Training (select one)
Individuals who have the job responsibility of supervising PAT parent educators are required to attend the first 2 days of Institute. This includes
supervisors starting a new PAT program and new supervisors of existing programs. Included in the 2 days is a special ½ day session for
supervisors only. It is highly recommended that supervisors attend the full week when possible. It is necessary that each supervisor have a Supervisors
Manual & Program Administration Guide for this training. It would also be helpful to bring Module A & B of the 2005 Born To Learn ™ Curriculum for
If you have curriculum from a PE who has left your program, you do not need to purchase new curriculum.
Name of PE being replaced SSN
Date(s) of Institute Registration Deadline
Location of Institute
Born to Learn TM Institute Prenatal to 3 Years Costs Quantity Cost Line Total
Training Fee for Two Day Supervisor 125.00
Training Fee for Five Day Supervisor 600.00
Curriculum (Includes one set of Modules A, B & C and one media component.) 295.00
Do you want Modules in English or Spanish? English Spanish
Which media you want? (Choose one; additional media available below.)
5 Videos Set (English) 5 Videos Set (Spanish) DVD (English & Spanish)
Additional 5 Video Set in English (optional) 37.50
Additional 5 Video Set in Spanish (optional) 37.50
Additional DVD - English & Spanish (optional) 27.50
Supervisor's Manual & Program Administration Guide (1 per program) 75.00
Late Fee (if received after deadline, $25 for 2 Day or $50 for 5 Day)
Method of payment: PO Check We do not accept credit cards TOTAL
Party responsible for payment:
IMPORTANT INFORMATION YOU NEED TO KNOW!
1 This form MUST be returned ALONG with the Participant Data Form and the Terms of Agreement Form. Three ways to submit Information:
● Fax to: Karen Apitz 920 893-5876 Checks and Purchase Orders made out to: Parents Plus Inc.
● Email to: email@example.com
● Mail to: Parents Plus Inc. 1215 Eastern Ave Plymouth, WI 53073
2 These forms must be filled out COMPLETELY or they will be returned to you for any missing information.
3 Do not assume you are registered until you receive verbal or written confirmation! Confirmation packets are sent within 2 weeks of Institute.
4 Do not book airline or hotel reservations, etc., until you receive confirmation!
5 The National Center reserves the right to change fees at any time.
6 For questions on institute, location and or lodging contact Karen Apitz (920) 893-5875
7 Make your checks or purchase orders out to Parents Plus Inc.
8 Cancellation Policy: Parents Plus reserves the right to cancel a state training in the event of insufficient registrations.
Participants may cancel their training prior to the registration deadline and receive credit to attend a future WI training.
No refunds are given after the first day of training.
9 Please keep a copy of this registration for your records.
Office Use Only
Date Received Approved by Guide purchased? Y N
Type of Payment Confirmation sent PAG purchased? Y N
Amount Rev March 2006
Born to Learn™ Institute Prenatal to 3 Years
Participant Data Form for Supervisors (SUP)
Please answer the following questions to help us better meet the needs of Institute participants.
This data MUST be on file two weeks prior to the Institute date!
Name Date of Institute
1 Briefly describe your educational background and supervised experience working with children birth to age 5.
Completed in school: GED HS Diploma CDA AA
B.S./B.A. - Field: Graduate Study - Field:
State experience, length of time, type of program, etc.
2 Is English a second language? yes no Primary language:
3 In your program, what will your role be? supervisor / administrator (no direct service to families)
supervisor / parent educator (some direct service to families)
Briefly describe your supervisory responsibilities.
1 Do you have funding in place to start and operate a PAT program? yes no
What are your funding sources? (Please be specific.)
What is the duration of current funding?
2 Will you be initiating a new Parents as Teachers program? yes no
If no, what was the start-up date of the PAT program you are joining?
3 Will PAT become part of a child care center, preschool or other center-based program? yes no
If no, please go to question 4. If yes, briefly describe the program and how PAT will be integrated.
Are you a classroom teacher in your program? yes no If yes, what ages do you work with?
Please indicate your program's Accreditation Status:
National State In self-study phase of accreditation Licensed
4 Describe the specific population(s) you plan to serve in the Prenatal to Three program.
What is the estimated number of total program participants?
Estimate the percentage of families who will meet the following criteria:
Families with low income Teen parents
Families with English as a second language Families with middle or upper income
Families with children with special needs Families with low literacy
Rev March 2006
Born to Learn™ Prenatal to 3 Years
Terms of Agreement for Programs
The following conditions are required for initial and ongoing implementation
of the Born to Learn ™ program.
1 New parent educators and supervisors will attend the Born to Learn Institute and complete all requirements for
parent educator or supervisor certification before delivering the Born to Learn model.
● Each parent educator and supervisor that serves families is required to attend the 5 day Institute (see Parent Educator Terms of
Agreement). Supervisors not serving families must attend the first 2 days of the Institute and are strongly encouraged to attend all
● The supervisor completes and maintains a Born to Learn program plan which is reviewed with every new
parent educator prior to attendance at the Institute.
2 The Born to Learn program that our organization sponsors will implement all four components of the
Born to Learn model:
● Regularly scheduled personal visits
● Regularly scheduled group meetings
● Regularly scheduled health, hearing, vision and developmental screenings
● Linkage with community resources and a referral network
3 Our organization will use the Parents as Teachers quality standards to guide our Born to Learn program's
services, operations, and management. The Parents as Teachers standards establish a blueprint for quality implementation of the
Born to Learn program, based on best practices in the field of early childhood home visitation.
4 The program supervisor and all parent educators will recertify with the National Center annually. Recertification maintains a
program's affiliation with the National Center and facilitates staff members' professional development that is essential to high quality
5 Our organization will complete and submit an Annual Program Report for our Born to Learn program by the required date
each year. In order for the National Center to advocate for families and children and develop resources to best meet the needs of
Parents as Teachers programs and the families they serve, an annual program report that summarizes the program's yearly service
delivery is required.
6 Our organization will acknowledge use of the Parent as Teachers Born to Learn curriculum and training in program
dissemination materials and evaluations. By using the Parents as Teachers Born to Learn name and logo, your program
acknowledges its affiliation with Parents as Teachers. This affiliation establishes recognition of quality programming and provides
opportunities to network with other Parent as Teachers affiliates.
7 The Born to Learn Curriculum Guides, Videos and DVDs are copyrighted and will be used only by currently certified parent
educators within the Born to Learn program. If Parents as Teachers Born to Learn is no longer implemented in our organization,
the Born to Learn Curriculum Modules, Videos or DVDs will not be used.
8 The copyrighted Parents as Teachers Born to Learn Curriculum Modules, Videos and DVDs are the property of affiliated
Parents as Teachers programs and are not the property of individual parent educators. If a parent educator leaves her
position, the supervisor will collect any of the parent educator's Born to Learn Curriculum Modules, Videos or DVDs.
Compliance with the above items in this Terms of Agreement for Programs signifies that the Born to Learn program is in good
standing with Parents as Teachers National Center, Inc.
Signature of Supervisor:
(please print name)
Person with Signature Authority in the Organization:
(please print name)
Program Name Program Phone Number
Program Address Program Fax Number
Date of Institute Location of Institute
Along with any electronic copy of this file that you may submit to firstname.lastname@example.org we require a printout of this
page with signatures to:
Rev March 2006