Ohio Connection State Family Child Care Association

Conference Application

Name ____________________________County__________________________

Address: _______________________________,OH  Zip ___________________

Phone_____________________ Email Address: __________________________

Provider Type

 ___ Certified Professional Type B _____Type A ____Limited ___PPI

____Registered  _____Private

If you have a local association, what is the name of the association?  _______________________________________________________________ Are you a member? ______ Who is the contact person? ______________________________

How many years have you been a provider? ______

Are you accredited? _____    If no, are you in the process of being accredited? ______

Do you have a CDA? ____    If no, are you in the process of getting a CDA? ________

EDUCATION:  Check the highest level of education you have completed.

High School (Diploma or GED) _____             Bachelors Degree ______

Associate Degree ______                                            Masters Degree    ______

Certificates _______                                                    Doctorate Degree ______

If you have a degree or certification, what is the degree or certification in? ________________________________________________________________

Conference Rates:  Early Bird Registration payment must be received prior to August 30th.

Members-Two Day Registration  $85  ______One Day Registration  $60________

Nonmembers Two Day Registration $135

Refunds/Cancellations

Registration refunds will be made only upon receipt of written request received by September 30, 2009 An administrative fee of $25 will be deducted.  Telephone cancellations are not accepted.  You can submit your cancellation request to Amelia Rodgers, 5527 Rose Terrace, Dayton, OH   45415.  Refunds will be issued within 90 days.  After September 30, 2009 there will be no refunds, but registration can be gifted to another person.

Please note that children are not allowed in any of the workshops.

CEU's will be available for an additional $10.

Full conference attendance will provide 10 credit hours of training.