Structured Literacy Practicum Application

Registration for this badge requires two steps:

Complete the registration form below.
Complete payment online through link provided upon submission of registration form.

First Name:
Last Name:
Date of Birth:
Email:
Phone:	( ) - Second three digits Last four digits
Address:
City:
State:
Zip Code:
Course Date Attending:	*Note: Badge 4 has 12 extra days built into it due to the holidays.
Have you previously attended Carroll:	Yes No
Highest level of education completed: