REGISTRATION FORM Send registration & payment to: Child Care Solutions 6724 Thompson Road Syracuse, NY 13211 You can also register on-line at our website www.childcaresolutionscny.org.
Name (one form per person): ____________________________________________________________ Program Name: ______________________________________________________________________ Mailing Address: _____________________________________________________________________ street address city state zip Daytime phone: _________________________________
Are you a Member?
Y
N
(circle one - if Y don’t forget to use preferred Member Rates)
E-mail address: ____________________________________________________________________________ (required for Distance Learning courses & MAT Skill Sessions - PRINT CLEARLY)
Date
Time
Location
Workshop Title
Copy this form as needed for each enrollee.
Cost
TOTAL $
Payment Options: Check/Money Order: # _______________________________________
Signed EIP award attached:
Y
Visa/MasterCard: Acct # ______________________________________
Expiration Date: ___________
Card Holder Name if different from enrollee: _____________________________________________________
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