Student Registration Request Form

Student Name

First Name *

Last Name *

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Student Job Title (Required)

Student Phone (Required)

Student Email (Required)

Student Date of Hire (Required)

Agency Name (Required)

Agency Contact (Required)

Agency Phone (Required)

Agency Email (Required)

Please enroll student in the following course: (Required)

Training Date (if multiple days, select start date)

Month

Day

Year

*Please check the dates the training is offered.

Continuing Education Course Name

Does your student require ASL interpreters? Please check the appropriate option:

Yes - My agency will schedule and pay for all interpreting services, and provide this information to PSRS
*Yes - Please schedule an ASL interpreter for the student
No Interpreter

*PSRS frequently schedules ASL interpreters for trainings. If PSRS has already scheduled an interpreter for your requested session, you agree to be responsible for a portion of the payment depending on the number of Deaf students. Payment will be based on the number of total Deaf students divided by the number of training days. If PSRS has not already scheduled interpreters for the session, we request that you make the necessary arrangements and provide the information to the PSRS trainer.

Do you require any accommodations we should know about?

Please Note: You are submitting a training request. PSRS gives priority to our staff, and may not have availability in the class you wish to register for. You will receive an email from the PSRS Training Team soon containing more information about the status of your request.

40 Hour Core Training Reimbursement

This training is required to be completed within the first 120 days of employment for all students. The registering agency may be responsible for submitting payment for the course if PSRS is unable to bill DDA. This fee will be invoiced to the agency and contact indicated on the registration request form.