Training Academy

840 SW 81st Avenue, North Lauderdale, FL 33068

Training Registration– Please Print Clearly and Return by: MONDAY AUGUST 22, 2016

Name of Training: _Birth Through Five Florida Child Care Professional Credential and/or the CDA

National Credential

Location of Training: Script-Fully U Enrichment, Inc. 2915 East Tamarind Avenue West Palm Beach, FL 33407

Date: Mondays and Wednesdays September 12, 2016- January 18, 2017

Time: 6:30 p.m. – 9:45 p.m.

Registration Fee: $50 Books: $110 Tuition: $1375 REGISTRATION FEE IS NON-REFUNDABLE

Name: Social Security #: XXX-XX- (required)

Address: City/State/Zip:

Home Number: Cell Phone: Work Number:

Email Address:

Employer: Employer’s Phone #:

Employer’s Address:City/State/Zip:

Employer E-mail address

Which best describes the age group that you work with most? CHOOSE ONE

Infant /Toddler (birth to 36 months) Preschool (3-5 years) School Age Children (5-11 years)

Please select 1 (one): FCCPC CDA National Credential

Please select 1 (one) Area of Specialization: Infant/Toddler Preschool Family Child Care Home

Payment Information: Please return this form with the $50 non-refundable registration fee to Family Central Training Academy at the above address by _AUGUST 22, 2016__. You may FAX the registration form and call in a credit card payment to 954-724-3957.

You may be eligible for a scholarship to assist you with the cost.

Please contact TEACH at www.teach-fl.org for a scholarship application or 1-877-358-3224.

Training Academy

840 SW 81st Avenue, North Lauderdale, FL 33068

Training Registration

ACKNOWLEDGEMENT

1. Your space in the class is not guaranteed without this form and payment. Please make payment to Family Central Training Academy at the above address. DO NOT MAIL CASH! Mail-in registration must be received by date above. Family Central, Inc. will not be responsible for lost or delayed documents. It is the responsibility of the participant to call and verify receipt of registration. If the class is full, you will be notified. Registration fees are non-refundable. Save receipt for proof of payment. Money orders, credit cards or company checks only! No personal checks please!

2. Children, friends and family members are not permitted in any training session. Only paid participants are allowed in class. Please read handbook for all course policies. Handbook will be reviewed on the first night of class.

3. For more information on trainings, call Training Academy Hotline (954) 724-3957.

4. Participants must be able to read, write and speak English.

I hereby acknowledge that the information I am sharing with Family Central Training Academy can and may be shared with state and local agencies for the purpose of seeking scholarship dollars.

Print Name:

Electronic Signature: Date:

Confirm Signature: _____________________________ Date:_______________