Born to Learn ® Institute Prenatal to 3 Years Event ID #
Registration Form for Supervisors (SUP)
Note: If you are a supervisor who will also be serving families, fill out Supervisor registration form only
If you are a supervisor of a new BTL program, you do not have to complete the last page - Terms of Agreement
Name SSN # (last 4 digits)
Home address Phone (cell / home)
City, state, zip+4 Email (primary)
Program name Office phone
Office address Fax number
City, state, zip+4 Program code
If you will be serving families and you have a BTL 2005 curriculum from a parent educator (PE) who has left your program, you do
not need to purchase new curriculum. Please indicate the name and PAT ID # (if known) of the PE being replaced / transferring
Name PAT ID #
Date(s) of Institute February 1-5, 2010 Registration Deadline Friday, January 08, 2010
Location of Institute UW Extension 9501 Watertown Plank Road Wauwatosa, WI
Born to Learn Institute Prenatal to 3 Years Costs Quantity Cost Line Total
2-Day Training Fee for Supervisor 150.00 $ -
5-Day Training Fee for Supervisor 650.00 $ -
Curriculum (Includes one set of Modules A, B & C and DVD.) 295.00 $ -
Do you want Modules in English or Spanish? English Spanish
BTL Curriculum Prenatal to 3 Years Spanish Parent Handouts on CD (optional) 50.00 $ -
Additional DVD - English & Spanish (optional) 27.50 $ -
Supervisor's Manual and Program Administration Guide (1 per program) 75.00 $ -
A Closer Look…the PAT Standards & Self-Assessment package (1 per program) 75.00 $ -
Guide to Health, Hearing and Vision Screening (optional) 45.00 $ -
Late Fee (if registration is received after deadline date) $30 for 2-day; $75 for 5-day - $ -
Method of payment: PO Check Credit Card Total $ -
Agency responsible for payment:
Make checks and purchase orders payable to National Center for Parents as Teachers
Important information you need to know
Individuals who have the job responsibility of supervising PAT parent educators are required to attend the first 2 days of the Institute.
This includes new supervisors starting a new PAT program and new supervisors of existing programs. In order for any new parent
educator to attend Institute, the program's supervisor must attend at least the first 2 days of the Institute. Included in the 2 days is a
special half day session for supervisors only. We highly recommend supervisors attend the full week of training when possible. Each
supervisor must have a Supervisor's Manual & Program Administration guide for this training. A Closer Look...the PAT Standards
and Self-Assessment Guide should also be purchased. Only supervisors who serve families need to purchase curriculum; however,
it is available for purchase by all supervisors. It is helpful for supervisors to bring the 2005 Born to Learn curriculum for reference.
1 This form must be filled out and returned along with the Terms of Agreement for Programs form. Please respond to every question fully.
Incomplete registration forms will delay the processing of your registration. Either type or print neatly with no abbreviations.
2 Submit your registration packet one of three ways: Email to firstname.lastname@example.org or Fax to Karen apitz 920-893-5876 or Mail to
Parents Plus 1215 Eastern Avenue Plymouth, WI 53073
3 Do not assume you are registered or make any travel arrangements until you receive verbal or written confirmation. Confirmation packets are
emailed within 2 weeks of Institute.
4 For questions regarding registration or on-site information and lodging, call Karen at 920-893-5875
5 Cancellation Policy: PATNC reserves the right to limit enrollment or cancel an institute in the event of insufficient registrations. Participants may
cancel their registration and receive a 90% refund prior to the first day of institute or receive full credit to attend another institute. No refunds will
be given after the institute begins.
6 If you are a new PAT program, you must bring the New Program Plan and a copy of this registration packet with you to the institute. If
you are with an existing PAT program, you must bring a copy of your program's latest Annual Program Report (APR) and this
registration packet to the institute.
Office Use Only
Type of Payment Approved by: New Program Plan attached Yes
Amount ELL Yes Language Terms signature needed Yes
page 1 of 2 revised November 23, 2009
Please answer the following questions to assist us in providing you with an optimal training experience.
Name Date of Institute February 1-5, 2010
Has applicant ever been a certified Parents as Teachers Born to Learn parent educator? Yes No
1 Briefly describe your educational background and supervised experience working with children birth to kindergarten:
Check the highest level of education you have completed:
less than Associates Associates Bachelors - Field
Masters - Field Beyond Masters - Field
2 Is English your first language? yes no If no, Primary language:
If English is your second language, place an X in each row that best describes your English speaking, understanding, reading
and writing skills.
Cannot do it at all (1) Very hard to do (2) Hard to do (3) A little hard to do (4) Easy to do (5)
3 In your program, what will your role be? Supervisor / administrator (no direct service to families)
Supervisor / parent educator (some direct service to families)
4 If you checked "Supervisor / parent educator" for question 3, please answer the following questions regarding the program
services you will be providing:
a How may families will you serve? (caseload size)
b How often do you visit families? weekly every 2 weeks monthly other (explain)
c Will your program provide 3 plus years of services (prenatal to 36 months) to families? yes no
If no, explain
5 Will you be a supervisor with a new PAT program? yes no
6 Will you be a supervisor with an existing PAT program? yes no
If you answered yes to question 6, please answer questions 7-9.
7 Are you replacing a supervisor who has left or is leaving this program? yes no
If yes, please provide the name of this supervisor and his or her PAT ID #
Previous Supervisor's name PAT ID #
8 Is this a new supervisory position as a result of program expansion? yes no
If yes, please describe your program's expansion:
9 Funding - Has your program received new funding since your last Annual Program Report (APR)? yes no
If yes, please check all source(s) of funding that apply.
Federal funding State funding Local Public funding Private funding
10 How does your program provide for:
Developmental screenings? completed by program staff OR outsourced
Functional hearing checks or screenings? completed by program staff OR outsourced
Functional vision checks or screenings? completed by program staff OR outsourced
Completion of the Born to Learn Health Record? completed by program staff OR outsourced
11 How many group meetings are offered each year?
12 Will it be your responsibility to deliver group meetings? yes no
page 2 of 2 revised November 23, 2009
Terms of Agreement for Programs
T The following conditions are required for initial and ongoing implementation
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 5 days.
● 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
● Regularly scheduled
Born to Learn model: 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 services.
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 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 your
organization, the Born to Learn Curriculum Modules or DVDs will not be used.
8 The copyrighted Parents as Teachers Born to Learn Curriculum Modules 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 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 National Center for Parents as Teachers, Inc.
Signature of Supervisor Date
(please print name )
Person with Signature Authority in the Organization Date
(please print name ) Program Code
Program Name Program Phone Number
Program Address Program Fax Number
UW Extension 9501 Watertown Plank Road Wauwatosa, WI February 1-5, 2010
Location of Institute Date of Institute
Along with any electronic copy of this file, submit a printed page with signatures to the Registration Specialist
via fax: 920-893-5876; via scan and email to email@example.com;
or via mail: Parents Plus 1215 Eastern Avenue Plymouth, WI 53073
revised November 23, 2009