1415 W. Cypress Creek Road, Suite 103
Fort Lauderdale, FL 33309
Training Registration
Please Print Clearly Return by: Friday, September 29, 2017
Name of Training:FCCPC Training | NorthCohort CEUs: 120 Hours
Location of Training: Family Central, Inc. 1415 W. Cypress Creek RD, Suite 103, Fort Lauderdale, FL 33309
Date: Mondays,October 2, 2017–June 4, 2018 Time:6PM – 9:45PM
RegistrationFee:$50 Books: $110Tuition: $1375 REGISTRATIONTEXTBOOKFEE IS NON-REFUNDABLE
Name:
Last 4 digits ofSocial Security #: XXX-XX-(required)
Address:
City/State/Zip:
Home Number: Cell Phone:
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): Birth through Five FCCPC CDA National Credential School-Age FCCPC
Please select 1 (one) Area of Specialization:
Infant/Toddler Preschool Family Child Care Home Home Visitor
Payment Information: Please return this form with the $50 non-refundable registration fee to Family Central Training Academy at the above address by _Friday, September 29, 2017__. You may FAX the registration form to 954-724-3957 or make a payment at
You may be eligible for a scholarship to assist you with the cost.
Please contact TEACH at a scholarship application or 1-877-358-3224.
1415 W. Cypress Creek Road, Suite 103
Fort Lauderdale, FL 33309
PROPRIETARY INTEREST DISCLOSURE
Family Central, Inc. does not support, condone, or encourage the departments offering training events, to contract with instructors who may have a commercial interest in any products or services mentioned during the course of the event.
Such departments are highly advised and encouraged to utilize the training skills and knowledge of current employees throughout the agency.
As much as possible, training materials should be generic in nature. Materials provided free of charge by the Agency for Workforce Innovation, Department of Children and Families, Department of Health, Department of Education, or other such related governmental agencies or non-profit organizations, should be utilized.
The Training Academy Manager or department Program Administrator is responsible for approving all training content and materials. Should the training reference a specific product, material, instrument, or service, the Training Academy Manager or Program Administrator is accountable for ensuring that the instructor either has no proprietary interest or makes a full disclosure.
Family Central, Inc. reserves the right to dismiss any instructor who fails to make a full disclosure regarding proprietary interest with regards
to any aspect of a training event.
In the unlikely event that an instructor does have proprietary interests and is still contracted to conduct a training or workshop, this
information will be communicated to prospective participants prior to the start of the program through promotional avenues.
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 ofseeking scholarship dollars.
Training Registration
ACKNOWLEDGEMENT
- 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!
- 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.
- For more information on trainings, call Training Academy Hotline (954) 724-3957.
- 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: ______
(PLEASE NOTE: Participant will be asked to sign this registration form upon the first day of class)