Center Application Form

Center Member Category - Application Form

Fields indicated by * are required.

Center Name:*
Business Name:*
Address:*
City:*
State/Province:*
Zip/Postal Code:*
Country:*
Center Director/Board/Chair Name:*
Phone:*
FAX:
E-mail:*
Website:*

ACENA CE Center category membership is provided to centers who meet the following definition:

For a CE Center to be granted ACENA member status, all fulltime employees (FTEs) who work more than 20 hours each week for 6 months or more in a calendar year must have a current ACENA individual membership. This would include all conductors (CETs), the program administrator (PA) and any related credentialed professionals (RCPs – e.g., physiotherapists). There is no fee for ACENA Center membership.

I acknowledge as the principal person responsible for: that all fulltime employees (FTEs) working more than 20 hours each week for 6 months or more in this calendar year are currently registered as individual ACENA members.

Name:*

Date:*

CENTER DEMOGRAPHIC/STATISICAL Details

In order to successfully lobby and advocate for CE, ACENA needs accurate statistics, which when consolidated across the United States, Canada and Mexico, portrays a full picture of the state of conductive education in North America. Please fill out the entire form.


Statistical Information		Your Center

1. Number of full-time staff working at your center.		Administration/Manager Conductor PTS OTs Aides/Assistants Other Other Staff

2. Number of children served annually		#

3. Number of service hours provided to children annually		HRS

4. Presenting conditions of children - annual percentages - must total to 100%		% Cerebral Palsy % Spina Bifida % Developmental Delay % Pediatric Stroke % Traumatic Brain Injury % Syndromes % Other Other Conditions

5. Number of adults served annually		#

7. Presenting conditions of adults - annual percentages - must total to 100%		% Cerebral Palsy % Stroke Survivor % Parkinson's % Multiple Sclerosis % Traumatic Brain Injury % Syndromes % Other Other Conditions

8. Type of services provided - check all that apply		Parent and Child Preschool with academic program Intensive camps for children Summer camps for children After School Child program without academic program Other Other Services

9. Sources of funding (by percentage)		% Fee for service/tuition % Foundations % Grants % Provincial/City funding % Fundraising % Other 100% Total

Center Member Category - Application Form

ACENA CE Center category membership is provided to centers who meet the following definition:

CENTER DEMOGRAPHIC/STATISICAL Details

Statistical Information

Your Center