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Complete the Following Form
* Denotes Required Field
*Date Completed OT-1:
If you are enrolling for attendance at registered child care ministry training and have not attended OT-1, enter N/A.
*Name of Facility:
*Name of Religious Organization: (Registered Child Care Ministry Only, otherwise N/A)
*Address:
*City:
*State:
*Zip Code:
*County:
*Phone Number:
*E-mail Address:
*Type of Training:
*Are you currently operating a licensed facility? Yes No If yes, are you planning to send staff for additional training? Yes No Due to limited space, only two (2) persons per facility should attend.For registered ministry training, it is encouraged that one attendee be the pastor of the church; the executive officer of a religious organization (e.g. YMCA, YWCA, parochial school).Persons attending:
*Name:
*Title:
Name:
Title: *Training Date You Wish to Attend: Oct. 7, 2009 Nov. 4, 2009 Dec. 2, 2009 Jan. 6, 2010 Feb. 3, 2010 Mar. 3, 2010 Apr. 7, 2010 May 5, 2010 June 2, 2010 July 7, 2010 Aug. 4, 2010 Sept. 1, 2010 Oct. 6, 2010 Nov. 3, 2010 Dec. 1, 2010 *Please Select an Alternate Date: Oct. 7, 2009 Nov. 4, 2009 Dec. 2, 2009 Jan. 6, 2010 Feb. 3, 2010 Mar. 3, 2010 Apr. 7, 2010 May 5, 2010 June 2, 2010 July 7, 2010 Aug. 4, 2010 Sept. 1, 2010 Oct. 6, 2010 Nov. 3, 2010 Dec. 1, 2010
This form must be received 10 days prior to the requested training date. You will receive a confirmation if the training date selected has available spaces; however, if the training date is full you will be notified to select another date.
Please check that all questions are answered. We can only process this pre registration application if all questions have been answered and OT-1 has been completed for licensed center training only. Thank you.
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