St. Lawrence Child Care Council, Inc. | SLCCC Online Training Registration Form

WORKSHOP INFORMATION

Title of Workshop*

Date of Workshop*

Time of Workshop*

Location of Workshop *

Workshop Fee, Payment (If paying by check make payable to SLCCC)*

Check

Cash

EIP Award Voucher

Personal Information

First Name*

Last Name*

Email Address*

Confirm Email Address*

Home Phone*

Cell Phone*

Mailing Address*

City & State*

Zip Code*

How would you like us to communicate with you?*

Program Information

Name of Program*

Primary Contact*

Email Address*

License/Registration #*

Expiration Date *

Mailing Address*

City & State *

Zip Code*

Phone *

Fax*

Additional Information

Ages of children served? (check all that apply)*

What is your position?*

Lead Teacher

Assistant Teacher

Teachers Aid Director

Assistant Director

Program Coordinator Site Supervisor

Family Child Care Owner

Family Child Care Ass't. School-Age Director

School-Age Staff

Cook Other (please explain)

Highest level of education?*

Some High School

High School or GED

Credential - CDA/SACC

Some College

Associates Degree

Bachelors Degree

Masters Degree

Other (please explain)

Area of degree study concentration?*

Early Childhood Education

Elementary Education

Special Education Family Studies

Psychology

Human Services None

Other (please explain)

Do you have other certifications? (check all that apply)*

CPR

First Aid

MAT (Medications)

None

Other (please explain)

Primary language?*

English

Spanish

Chineese

French

Other (please explain)

Your ethnicity or race?

Please list topics you would like the St. Lawrence Child Care Council to provide or facilitate training on within the next 12 months (please list in order of interest/importance to you):

What is your preferred method of receiving training? (please rank in order of preference 1-10)

Weekday evening workshops

Weekday workshops

Nap time on-site workshops

Conference (2-5 workshops in same day)

Super Saturdays (2 workshops in same day)

Videoconferences

Distance learning/correspondence (ie. Care Courses)

Online courses

In-home Intensive Technical Assistance

College credit bearing courses

What is your preferred location for attending training? (please rank in order of preference 1-6)

Ogdensburg

Canton

Potsdam

Massena

Gouverneur

Norwood

We will contact you to confirm your registration. Thank you!