COURSE ONLINE
COURSE IN PERSON
ZOOM COURSE DATES
Full Name
Full Address (Street, City, State, Zip)
Cell Phone Number
e-mail address
Type of program you are working with:
If you check off Other, please enter the type of program.
Child Care Center Name & Full Address
Business Phone Number
Business E-mail Address
Mail Certificate To:
If you checked off Other, please enter information.
Reference List: Please list the name person that wrote your letter of recommendation:
How do you know this person?
List current child care center where you are employed:
Telephone Number
Refund Policy: Refunds are not issued for on-line and mail correspondence course. Refunds are issued for in person course only if notice is received 30 days prior to course date. This refund will be 50% of paid amount.
Credential Agreement: Participant agrees to the terms of this credential. This credential is valid for two years from issued date and must be renewed six months before anniversary date of issuance. A $75 renewal fee. A $25 late fee for renewals received after the expiration date. $25 rush order fee if requested. Request for renewal must be received within 6 months and must accompany 30 clocks per year (10-management, 10-child development, 10 child care of choice) and a copy of last licensing visit with no serious deficiencies. The course must be completed with a 70% passing score within 6 months on-line and mail course, unless you are attending the in person course. Credential will be revoked if participant does not respond or fails to renew at 6 months from expiration date. In addition the following will be grounds for reprimand; if credential holder is placed on probation by licensing or reoccurring serious deficiencies. Three reprimands will lead to credential being revoked. Credential holder will have the right to review if this occurs.
Signature of Agreement
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