Children's Aid & Family Service

Child Care Resources Registration Form
Please use this form to register for individual workshops, orientation, CEU series, First Aid and CPR.

General information about registration for workshops
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Pre-registration is required for all workshops.
All registration fees are non-refundable.

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You will be contacted only if your registration is not accepted.  All others should assume confirmation.
• All registration forms must be accompanied by payment, unless using purchase order. • Child Care Resources reserves the right to cancel workshops due to insufficient enrollment, and/or at our discretion.
• Space in workshops cannot be held without registration and payment. • Child Care Resources reserves the right to limit enrollment according to our training policy.
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PLEASE FILL OUT FORM COMPLETELY. COPY AND USE SEPARATE FORMS FOR EACH REGISTRANT. PLEASE PRINT INFORMATION.
Name (Please Print):____________________________________ Home Phone: _____________________________
Home Address:_____________________________City:______________________ State:______Zip:___________
Work Place:___________________________________ Work Phone:______________________________________ 

JOB TITLE (Please Check One):

School Age Staff
Administration Other:__________________
       
 
College Degree In a Degree Program   Yes No
ABE/ESOL Program   Persuing EEC Certification   


Workshop Registration
Training Title

 Date Fee
__________________________________________________________ _______________ ___________
__________________________________________________________ _______________ ___________
__________________________________________________________ _______________ ___________
__________________________________________________________ _______________ ___________
__________________________________________________________ _______________ ___________
Payment:
Providers have the option of paying by check, VISA or MasterCard.		    
Check enclosed payable to Child Care Resources VISA MasterCard
Name (as it appears on card):________________________ Signature: _____________________________________
Address (if different from registrant):_________________________________________________________________
Card #:__________________________________________ Expiration Date:_________________________________
CPC, Agency or System paying. Name of Payer: _________________________ Purchase Order #:___________
Are You interested in holding future trainings at your site? Yes No
Please mail completed form and payment to:
Child Care Resources
76 Summer St.
Suite 345
Fitchburg, MA 01420