Early Childhood Educator Training Registration Form

Instructor: Althea Penn, Educational Consultant

Bright from the Start DECAL approved trainer and training

Please print and complete all information.

NAME OF CENTER/SCHOOL/primary attendee: ___________________________________________________

Center OR Attendee STREET ADDRESS:___________________________________________ CITY ____________________

ZIP _________ PHONE NUMBER:___________________ FAX NUMBER:________________ E-MAIL ______________________

Type of Center: SCHOOL/Center ___ Group Day Care ___ Family Day Care___ WEBSITE _______________________________

Attendees

Name (Last, First)

Type of Registrant Owner, Director, Lead Teacher, Assistant Teacher, other

Years Exp.

Age Group Infants, Toddlers, Preschool, Kindergarten, or School Age

SESSION

Session Titles

Date/Time

Location

Adv. Reg.

Reg. onsite

# of Atten -dees

Amt Due

Please sign below after reading the following important information:

I understand that all registration fees are nonrefundable; however they may be transferred with prior approval (a minimum of two days prior to the training date). The advance registration deadline is fourteen business days prior to the training.

Mail the completed registration form along with a check or money order to:

Althea Penn, Educational Consultant, P. O. Box 49254, Atlanta, GA 30359

If paying by credit card email both pages to penntraining@yahoo.com

Photocopy as needed. Questions? Please call the training registration center at 678.557.8684

Signature ___________________________________ Date _____________ Check or m.o. # ____________________

Method of Payment-Charge Authorization Form

Mail or email to: Penn Consulting, P. O. Box 49254, Atlanta, GA 30359 or penntraining@yahoo.com.

I authorize Penn Consulting to charge my credit/debit card: o MasterCard o Visa the following fees and charges:

Registration fee director’s training ______________________

Per Diem (Travel expenses) at $.585/mile ______________________

Total charges ______________________

Name (as it appears on credit card):

Company ___________________________________________________________________________

Last ________________________________ First ________________________ MI ____________

Street Address ________________________________________________________________________

City _________________________________________________ State _____ Zip Code _____________

Phone ____________________________ Phone #2 ______________________

Card No. ____________________________________________________

Expiration Date _______________________ CVC No. (on back of card) ________________________

Authorized Signature _______________________________________ Date ___________________________