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					SPRING 2011                                                                                                           Non-Profit Org.
                                                                                                                      US POSTAGE
    COURSE                                                                    Everyone is a learner                   Northampton,
    CATALOG                                                                                                           Permit No. 47

                                                                     Collaborative for Educational Services

                                                                     (formerly Hampshire Educational Collaborative)
                                                                     97 Hawley Street

                                                                     Northampton, MA 01060
                                                                     FORWARDING SERVICE REQUESTED

                      Become a
          licensed educator,
renew your educator license,
or earn an additional license.

    E D U CATO R                                                     English as a Second Language . Reading
                                                                     Special Education . Mathematics . Math/Science
    LICENSURE                                                        General Science . Earth Science . Biology
    PROGRAMS                                                         Chemistry . Physics . School Administration

                                                                              AND 3 NEW PROGRAMS!
                                                                     History . English . Humanities

    After 35 years,
    HEC has changed
    its name.                                                                                                              2011

            Details inside.

PDPs, graduate credit, Master’s Degree and CAGS options available.
NEWS                                                    Meet Our Instructors

Name Changes, New Courses,                              Martha Batten has served in leadership roles in public and private schools in
                                                        Massachusetts and recently retired as principal in the Lexington Public Schools.
and New Programs
                                                        Matthew Beyranevand is a mathematics teacher and professional development
Watch for some new names as you visit our website       presenter for the Lowell Public Schools.
and look through our course catalogs:
                                                        Nancy Cheevers is a National Board Certified English/Language Arts teacher in
Collaborative for Educational Services                  the Northampton Public Schools.

The Hampshire Educational Collaborative                 Damon Douglas is a former classroom teacher who now serves as Coordinator of
has changed its name to the Collaborative for           Special Projects in Learning and Leadership at the Collaborative.
Educational Services—but you can call us C.E.S.,
                                                        Andrew Foster teaches in the Northampton Public Schools. He has taught typical
or the Collaborative. Our new name and look
                                                        and special needs students at all grade levels.
reflects our growth as an organization that serves
learners, educators, and communities throughout the     Carol Gregory has served as an administrator and teacher in Massachusetts and
Commonwealth. Only our name has changed.                recently retired as assistant superintendent in the Wellesley Public Schools.
All addresses, phone and fax numbers, e-mail
                                                        Martha Harrington retired from a career as a special education teacher and
contacts, and website URLs remain the same.
                                                        consultant in the Brookline Public Schools.
Fitchburg State University                              Maureen Henry is a reading specialist for the Shrewsbury Public Schools, where
Our higher education partner, Fitchburg State           she has also served as a literacy coach.
College, is now Fitchburg State University (FSU).       Rick Last is a Curriculum Implementation and Professional Development
                                                        Consultant for the Collaborative.
Positive Behavior Supports
                                                        Barbara Lindsay is Elementary Literacy Coordinator for the Westwood Public
Beginning this semester, Positive Behavior Supports
replaces Managing Challenging Behaviors. The
course addresses the same topics and meets the          Mary Morgan is a grant coordinator and Title I teacher for the Wareham Public
goals of the previous course.                           Schools.

                                                        Ken Pransky is a Curriculum and Instructional Consultant for the Collaborative’s
Introduction to Educational Technology
                                                        Center for English Language Education (CELE).
Beginning with the Fall 2011 catalog Impact of
Technology in Education will be called Introduction     Jennifer Rickard is a Lead Elementary Special Education teacher for the
to Educational Technology.                              Shrewsbury Public Schools.

                                                        Sanford Roth is a veteran classroom and special education teacher who is a
History, English, and Humanities Programs               Curriculum Specialist at the Collaborative.
With the Spring 2011 semester, we begin offering
                                                        Sue Smith is a recently retired Facilitator/District Support Specialist for the
our new History, English, and Humanities licensure
                                                        Lowell Public Schools.
programs. See Page 3 for a full list of our programs.
                                                        Janet Strauss is the Lead Massachusetts Facilitator for the National Institute for
Using Primary Sources                                   School Leadership
In the Summer 2011 catalog, you will see an entirely    Sidney Worthen is a literacy specialist in the Westwood Public Schools, who
new course. We have added Using Primary Sources,        previously worked as an attorney.
a challenging course that focuses on how middle
school and high school students can learn from
original source material. This course is required for
our newest licensure programs in History, English,
and Humanities.

                                                        “....course was enjoyable, practical, responsive to our
                                                         needs, and motivated me to be a better teacher.”

                                                 Teacher of English as a Second Language (PreK-6) (5-12)

                                                 Teacher of Middle School Mathematics (5-8)

           We offer educator
                                                 Teacher of Middle School Math/Science (5-8)
       preparation programs                      Teacher of Mathematics (8-12)
         for an Initial license                  Teacher of General Science (5-8)
                                                 Teacher of Biology (5-8) (8-12)
                in these areas                   Teacher of Chemistry (5-8) (8-12)
                                                 Teacher of Earth Science (5-8) (8-12)
        Courses and requirements for             Teacher of Physics (5-8) (8-12)
           the programs represented
                                                 Teacher of Students with Moderate Disabilities (PreK-8) (5-12)
         by each icon are detailed at:
                                                 Reading Specialist (All Levels)
        All preparation programs offer
       hybrid-online course options for          Administrator (PreK-6) (5-8) (9-12): Principal/Assistant Principal
      increased flexibility and access .         Administrator (All Levels): Superintendent/Assistant Superintendent
                                                 Administrator (All Levels): Supervisor/Director
                                                 Administrator (All Levels): Special Education Administrator

                                                 Teacher of Humanities (5-8)

NEW PROGRAMS                                     Teacher of History (5-8) (8-12)

                                                 Teacher of English (5-8) (8-12)

                                                                For more information about our licensure
                                                                programs, visit or contact us at:
                                                                413.586.4900 or 800.278.4244

                                                                                                                                 Affordable. Practical. Statewide.
              Educator Licensure Programs        Information Sessions
      Collaborative for Educational Services
(formerly Hampshire Educational Collaborative)   Opportunities to learn more about our educator licensure programs will be
97 Hawley Street, Northampton, MA 01060          scheduled at locations throughout the state during the coming months. Dates
                                                 and locations are posted on our website as they are confirmed.
           413.586.4900 . 800.278.4244
                          413.586.2878 fax       FIRST FRIDAYS IN NORTHAMPTON (4-5pm)
                                                 Regular information sessions are held on the First Friday of every month
                        from 4:00-5:00pm at the Collaborative main office at 97 Hawley Street,
                                                 Northampton. Bring your questions and sit down with someone to discuss
 The Collaborative for Educational Services
                                                 your options. We can help you to map out your program so you can begin
   is a public, nonprofit educational service
                                                 the path to a new career.
         agency serving schools and school
        districts, communities, and students     Fall 2010-Winter 2011: November 5, December 3, January 7, February 4, March 4
    with diverse learning needs since 1974.
                                                 School district information sessions may be scheduled on request.

           Everyone is a learner
 COURSE OPTIONS                                           The affordable, practical route to an Initial License.

Any licensure course may be taken as part of a            The Collaborative for Educational Services          exciting and grounded in experience.
Licensure Program or as an individual course.             is a respected leader in professional               Courses are offered throughout the year
Courses may be taken for:                                 development for PreK-12 educators,                  and participants enjoy a small-school
                                                          with over thirty years of experience in             learning environment that promotes
    • Professional Development Points (PDPs)
                                                          meeting the specific needs of teachers,             access and support.
    • Graduate Credit (additional cost)                   administrators, and school districts. The           Each license preparation program
    • Master’s Degree or CAGS from Fitchburg State        distinctive insights we have gained through         consists of six courses and a practicum.
      University (additional required courses and cost)   this work have guided us in developing              Many people complete these programs
                                                          innovative, high quality license preparation        in eighteen months while continuing to
                                                          programs that are designed by educators,            work full time, although enrollees may
                                                          for educators. The knowledgeable
COURSE LOCATIONS                                          professionals who teach our courses are
                                                                                                              take up to five years to complete the
                                                                                                              program. Through our higher education
                                                          experienced in their fields and understand          partner, Fitchburg State University,
                                                          the challenges facing teachers today—               licensure candidates may also elect to
*Holyoke                                                  because they share them.                            receive graduate credit or complete an
Kittredge Center
                                                          Our licensure programs provide a quick,             MEd or CAGS. Those already working
Holyoke Community College
                                                          practical, and cost-effective route to an           in schools have the opportunity to
303 Homestead Avenue, Holyoke, MA 01040
                                                          Initial License as a teacher or school              integrate their practicum into their work.
Lowell                                                    administrator that is both intellectually
C.W. Morey Eementary School
130 Pine Street, Lowell, MA 01851
*Northampton                                              Earn your Master’s in Education or Certificate of
Collaborative for Educational Services
(formerly Hampshire Educational Collaborative)            Advance Graduate Study (CAGS) through Fitchburg
97 Hawley Street, Northampton, MA 01060                   State University (formerly Fitchburg State College)
Quinsigamond Elementary School
14 Blackstone River Road, Worcester, MA 01607

Directions are available at:
*While we endeavor to meet students’ site                 For graduate program               In collaboration with Fitchburg State University
 preferences, we reserve the right to move courses        application procedures and         (FSU), licensure courses at all of our locations across
 between locations in the Pioneer Valley area to          more information, contact:         Massachusetts can also be taken for graduate credit.
 accommodate enrollment needs.                            Beverly Streeter                   • FSU graduate credits are available for each
                                                          HEC Licensure Programs               CES Licensure Program course for an additional fee
                                                          413-586-4900 x145                  • Registration for graduate credit and payment to
                                                          FSU occurs at the first session of every course

                                                          At Fitchburg State University:     Graduate credits earned through Collaborative
                                                                                             Licensure Program courses may be used toward a
                                                          Stephen Hemman                     Master’s Degree (MEd in Curriculum & Teaching)
                                                          Program Coordinator                or, for those who already have a Master’s Degree, a
                                                          978-821-2890                       Certificate of Advanced Graduate Study (CAGS) from
                                                                    Fitchburg State University.
                                                          Kathy McCoy                         A typical plan of study for the MEd includes:
                                                          Graduate & Continuing Ed.
                                                                                             • Collaborative courses required for licensure (18 credits)
                                                          Admissions Counselor
                                                                                             • A 3-credit seminar taken in conjunction with the
                                                                                             • 15 additional credits

                                                          TO EARN A GRADUATE               In conjunction with Fitchburg State University, the
                                                          DEGREE YOU MUST                  Collaborative prepares Educational Leaders who are
                                                          SUBMIT A PROGRAM                 KNOWLEDGEABLE, ETHICAL, SKILLFUL,
                                                          APPLICATION TO FSU.              and CARING.
                                                          EARLY ENROLLMENT
                                                          IS ENCOURAGED.
                                                                                                                    GRADUATE CREDIT
Spring 2011
                                                                                                           Hybrid online options for our
                                                                                                           Northampton-based Administrator
                                                                                                           program offer increased flexibility
                                                                                                           and access.

The Culture of the School
This course teaches prospective administrators how to create a more flexible culture focused on
problem solving, learning, and successful communication in their school/school district community.
Prospective administrators learn how to recognize what can be mandated and when mandates make
sense, what is susceptible to problem solving and when issues are best dealt with collaboratively,         Level: K-12
how and when to focus on instructing members of the school/school district community, and how              67.5 PDPs | 3 Graduate Credits
and when not to intervene. There is a particular focus on strategies and techniques for problem            Course required for Licensure Program
solving, collaborative work, and successful instruction of adults.
                                                                                                           Course Format: Hybrid Online
Instructor:              Janet Strauss
                                                                                                           3 in-person sessions (Saturdays, 9:30am-
Hybrid online course: Online coursework plus 3 in-person meetings in Northampton
                                                                                                           12:30pm): Jan 29; Mar 5; Apr 2 (Course ends)
Register by:             January 12, 2011 ($50 late fee applies after this date)                           NORTHAMPTON

The Contemporary Educational Leader
This core course explores the significant issues and relevant research affecting individual and
systemic educational leadership. Candidates will actively investigate such topics of contemporary
concern as diversity, reform movements, the profession of teaching, the power of leadership,
creative curricula, innovative learning environments, the promise and potential of new educational         Level: K-12 | 67.5 PDPs | 3 Graduate Credits
technologies, equity in funding, and financial megatrends. The course will provide administrators          Course required for Licensure Program
and staff developers with new insights into the key ideas and critical components of proactive
leadership and ways to assure that schools under their leadership “teach all students.”
                                                                                                           Course Format: Hybrid Online
Instructor:              Martha Batten and Carol Gregory                                                   3 in-person sessions (Saturdays, 1-4pm):
Hybrid online course: Online coursework plus 3 in-person meetings in Northampton                           Apr 2; May 7; Jun 4 (Course ends)
Register by:             March 16, 2011 ($50 late fee applies after this date)                             NORTHAMPTON

Learning Disabilities & Instructional Techniques
The course is a survey of the general field of learning disabilities, including history and definitions,
as well as assessment and remediation. The course looks at the underlying neuro-developmental
functions of the brain and how differences in brain functioning can lead to difficulties learning in
school and can impact job performance in the workplace. The impact of these learning differences           Level: K-12 | 67.5 PDPs | 3 Graduate Credits
on individuals and on society is considered                                                                Course required for Licensure Program

Instructor:              Mary Morgan, Martha Harrington, Jennifer Rickard
Traditional course:      In Northampton                                                                    Course Format: Traditional Classes
Hybrid online course: Online coursework plus 3 in-person meetings in Holyoke or Worcester                  Tuesdays, 4:30-7:30pm:
Register by:             January 12, 2011 ($50 late fee applies after this date)                           Feb 1, 8, 15; Mar 1, 8, 15, 22, 29;
                                                                                                           Apr 5, 12, 26; May 3, 10

                                                                                                           Course Format: Hybrid Online
                                                                                                           3 in-person sessions (Saturdays, 1-4pm):
   A $50 late fee will be applied for all            IMPORTANT INFORMATION                                 Jan 29; Mar 19; May 14 (course ends)
   registrations received after 5:00pm                                                                     HOLYOKE, WORCESTER
   on the date noted in each course
   A maximum class size will be set for
   each course. Registrations will be                  Inclement Weather:
   accepted on a first-come, first-served
   basis, and must include payment.                    Any delays or cancellations are
   If the number of registrations for a                posted online at
   course exceeds the maximum seats                    and at
   available or is too low to be able to
                                                       You may also call 413.586.4900
   conduct a quality learning experience,
                                                       after 6:30am for information about
   the Collaborative will inform you of
                                                       morning classes, and after 12:00pm
   available options.
                                                       for afternoon class information.                                                               5
Spring 2011

Principles of Sheltering Instruction
The essential question that will guide this course is: How can we design curriculum and classroom
practices to simultaneously develop the language and content knowledge that is necessary to meet
the goals of students, the expectations of their families and community, and the expectations of
the broader society? Coursework centers on curriculum projects that will be developed in small,            Level: K-12 | 67.5 PDPs | 3 Graduate Credits
collaborative learning groups for use in classrooms that use group work methods for English language       Course required for Licensure Program
and content learning. The curriculum projects, along with course reading/writing tasks and group
discussions, are the vehicles for exploring the question posed above, and much of what we produce
will be jointly generated as we work together.
                                                                                                           Course Format: Hybrid Online
                                                                                                           3 in-person sessions (Saturdays, 9:30am-
We will join in a dialogue about “standards-based” education by aligning our work with various             12:30pm): Feb 5, Mar 26, May 21 (Course ends)
standards, including Massachusetts ELPBO (English Language Performance Benchmarks and
Outcomes), the state Curriculum Frameworks for subject matter, and TESOL (Teachers of English
to Speakers of Other Languages) standards. We will critically reflect on how these affect English
language learners. We will also learn about the SIOP (Sheltered Instruction Observation Protocol).

Instructor:             Ken Pransky
Hybrid online course:   Online coursework plus 3 in-person meetings in Worcester
Register by:            January 19, 2011 ($50 late fee applies after this date)

Literacy Learning for Pre-Adolescents and Adolescents
This course is designed to assist participants in teaching intermediate students, including English
language learners, to read and write and to use literacy skills for a variety of purposes. Sessions will
focus on implementing effective literacy practices with groups of students, using observations of
                                                                                                           Level: K-12 | 67.5 PDPs | 3 Graduate Credits
students’ reading and writing behaviors to effectively plan for different learners, and establishing a
                                                                                                           Course required for Licensure Program
supportive, well-managed environment for learning. Participants will gain experience in observational
assessments, lesson planning, guided reading, writing process, and language/word study.

Instructors:            Nancy Cheevers, Barbara Lindsay and Sidney Worthen                                 Course Format: Traditional Classes
Traditional course:     In Northampton, Lowell                                                             Thursdays, 4:30-7:30pm:
                                                                                                           Mar 3, 10, 17, 24, 31; Apr 7, 14, 28; May 5,
Hybrid online course:   Online coursework plus 3 in-person meetings in Worcester
                                                                                                           12, 19, 26; Jun 2
Register by:            February 9, 2011 ($50 late fee applies after this date)
                                                                                                           NORTHAMPTON, LOWELL

                                                                                                           Course Format: Hybrid Online
                                                                                                           3 in-person sessions (Saturdays, 9:30am-
                                                                                                           12:30pm): Feb 26, Apr 2, Jun 4 (Course ends)

Literacy Learning for Younger Children
This course provides students with an in-depth study of elements of an early literacy instructional
framework, with a focus on the reading components. Included in the course of study are
investigations of the following: Reading comprehension, interactive reading aloud to students,
assessment of reading skills, shared reading, guided reading, independent reading, and word study.         Level: K-12 | 67.5 PDPs | 3 Graduate Credits
Students are expected to effectively implement each of these elements into a typical classroom             Course required for Licensure Program
study with a theoretical understanding of why particular instructional decisions are being made.

Instructors:            Maureen Henry, Sanford Roth                                                        Course Format: Traditional Classes
Traditional course:     In Northampton                                                                     Mondays, 4:30-7:30pm:
                                                                                                           Jan 31; Feb 7, 14, 28; Mar 7, 14, 21, 28;
Hybrid online course:   Online coursework plus 3 in-person meetings in Worcester
                                                                                                           Apr 4, 11, 25; May 2, 9
Register by:            January 12, 2011 ($50 late fee applies after this date)

                                                                                                           Course Format: Hybrid Online
                                                                                                           3 in-person sessions (Saturdays, 1-4pm):
                                                                                                           Jan 29; Mar 19; May 21 (Course ends)
Spring 2011                                                                                             Licensure Program Icons:
                                                                                                        See Page 3 for a complete list of
                                                                                                        programs and icons.

Teaching for Mathematical Understanding
Through a focus on the curriculum and pedagogy of standards-based mathematics, participants
engage in problem solving and representing the mathematical concepts and professional teaching
standards of mathematics. Participants use a range of tools, including, but not limited to: graphing
calculators, hands-on manipulatives, electronic probes, and internet resources. The course addresses    Level: K-12 | 67.5 PDPs | 3 Graduate Credits
the application of the Massachusetts Mathematics Curriculum Framework (MMCF) and the                    Course required for Licensure Program
Massachusetts Professional Standards for Teachers (PST). Learning standards from all five strands
of the MMCF for grades K-8 and grades 9-12 are included, as appropriate, with an emphasis on
developing skills for improving instruction, assessment and student achievement.
                                                                                                        Course Format: Hybrid Online
                                                                                                        3 in-person sessions (Saturdays, 1-4pm):
Instructors:          Damon Douglas, Matthew Beyranevand                                                Feb 5, Mar 26, May 21 (Course ends)
Hybrid online course: Online coursework plus 3 in-person meetings in Northampton, Worcester             NORTHAMPTON
Register by:          January 19, 2011 ($50 late fee applies after this date)                           3 in-person sessions (Saturdays, 1-4pm):
                                                                                                        Feb 5, Mar 19, May 21 (Course ends)

Positive Behavior Supports (formerly Managing Challenging Behaviors)
The course addresses the differentiated approaches and the common approaches to successfully
educating together typical children and youth and those with the most challenging behaviors.
Course participants learn how to: create an environment that is conducive to learning; create a
physical environment appropriate to a range of learning activities; maintain appropriate standards      Level: K-12 | 67.5 PDPs | 3 Graduate Credits
of behavior, mutual respect, and safety; and use the appropriate management of classroom routines,      Course required for Licensure Program
procedures and student behavior as an element of instruction. These ways of working with all
children allow them to accept greater responsibility with adult guidance. The course is organized so
that there can be a focus, as appropriate, for course participants on younger special needs students,   Course Format: Traditional Classes
older special needs students, and typical middle school students.                                       Wednesdays, 4:30-7:30pm:
                                                                                                        Mar 2, 9, 16, 23, 30; Apr 6, 13, 27;
Instructors:          Martha Harrington, Andrew Foster, Sue Smith                                       May 4, 18, 25; Jun 1, 8
Traditional course:   In Holyoke, Lowell, Northampton, Worcester                                        HOLYOKE, LOWELL,
Hybrid online course: Online coursework plus 3 in-person meetings in Northampton                        NORTHAMPTON, WORCESTER
Register by:          February 9, 2011 ($50 late fee applies after this date)
                                                                                                        Course Format: Hybrid Online
                                                                                                        3 in-person sessions (Saturdays, 1-4pm):
                                                                                                        Feb 26, Apr 2, Jun 4 (Course ends)


The practicum is required for all licensure                 For questions, write:
programs and is included in the program cost.     
If your payments are up to date and you have
completed at least four courses, required MTELs,           Completed forms should be mailed to:
and all of your enrollment documents, you may              Practicum Coordinator
register for the practicum.                                Educator Licensure Programs
If you already possess an Initial/Professional             Collaborative for Educational Services
License and are seeking an additional license that         97 Hawley Street
requires a practicum (except Reading Specialist and        Northampton, MA 01060
Administrator licenses), the practicum fee is $1900.
Practicum request forms are available at:
                                                                                          PLEASE PRINT                   Spring 2011
                                                                                          CLEARLY AND                    COURSE SELECTIONS
                                                                                          EACH SECTION

                                MAIL OR FAX REGISTRATION FORM TO:                                                        Unless noted as ‘Hybrid Online,’ courses are

                                                                                                                         conducted in a traditional class meeting format.
                                Educator Licensure Programs, Attention: Ann Paquette
                                Collaborative for Educational Services
                                                                                                                         The Culture of the School
                                97 Hawley Street, Northampton, MA 01060
                                413-586-2878 Fax                                                                             Hybrid Online with 3 meetings in Northampton
                                                                                                                         The Contemporary Educational Leader
                                Last Name                                                                                    Hybrid Online with 3 meetings in Northampton

                                First Name                                                                               Learning Disabilities & Instructional Techniques
                                Home Address                                                                                 Hybrid Online with 3 meetings in Holyoke
                                City                                      State           Zip Code                           Hybrid Online with 3 meetings in Worcester
                                                                                                                         Principles of Sheltering Instruction
                                Home Phone with Area Code (                    )
                                                                                                                             Hybrid Online with 3 meetings in Worcester
                                Cell Phone with Area Code         (            )
                                                                                                                         Literacy Learning for Pre-Adolescents
                                E-mail                                                                                   and Adolescents
                                An e-mail address is required for all course participants.                                    Lowell           Northampton
                                Please visit our website ( for information about free                         Hybrid Online with 3 meetings in Worcester
                                e-mail accounts that are available through Google, Yahoo, and other providers.           Literacy Learning for Younger Children
                                School or Work Name                                                                           Northampton
                                                                                                                              Hybrid Online with 3 meetings in Worcester
                                School or Work Address
                                                                                                                         Teaching for Mathematical Understanding
                                City                                      State           Zip Code                           Hybrid Online with 3 meetings in Northampton
                                                                                                                             Hybrid Online with 3 meetings in Worcester
                                School Phone with Area Code (                      )
                                                                                                                         Positive Behavior Supports
                                School Fax with Area Code (                )
                                                                                                                             Lowell           Holyoke
                                School System                                                                                Northampton      Worcester
                                                                                                                             Hybrid Online with 3 meetings in Northampton
                                Position                                               Grade Level

                                All registration materials and forms are also available at


                                WITHDRAWAL POLICY (applies to all registrants)
                                If it becomes necessary to withdraw from a course, you must notify the Collaborative’s Licensure Programs office in
                                writing, attention Ann Paquette. Written withdrawals forwarded via mail to the address below, by fax (413-586-2878)
                                or by e-mail (, are accepted without penalty until 3:00pm, five calendar days prior to the
                                first meeting date. After that date there will be no refunds or billing adjustments.
                                I have read and I understand the above policy.

                                Signed                                                                                          Date

                                PAYMENT FOR INDIVIDUAL COURSES AND ANY                Form of Payment (individual course registrations and any late fees):

                                LATE FEES MUST BE INCLUDED WITH REGISTRATION              Check enclosed (Payable to Collaborative for Educational Services)
                                (Program enrollees are billed separately for tuition)     PO #
                                                                                                          Credit Card (ALL INFO below required):   Visa   MasterCard   Discover
                                Participation Level:
                                                                                                     Card Number
                                       Licensure Program Enrollee
                                                                                                     Expiration Date                                  V Code
                                       (Tuition payment plan per Commitment Letter)
                                                                                                     Name on Card
                                       Individual Course Registration
                                                                                                     Billing Address for Card
                                        $620 per course
                                       $50 late fee enclosed for each late course registration
                                                                                                     Total Amount to Bill to Card: $
                                  TOTAL: $                                                           Signature

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