Registration Form
MAIL TO: Early Childhood News P.O. 49579, Dayton, OH 45449-0579
PHONE (800) 543-4383 FAX (937) 847-5910

Enrollment: (check one)
___ Professional Development Certificate Option - 3 CEUs
YES, I want to enroll for three CEUs in the Early Childhood News Professional Development Program. I understand that upon successful completion of three CEUs within a 12-month period, I will be awarded a Professional Development Certificate from University of Wisconsin-Stout. Please start me with the next available issue (see program schedule below). My cost is $79, or $69 each for two or more to enroll.

___ Single CEU Option
YES, I want to enroll for one CEU in the Early Childhood News Professional Development Program. I understand that upon successful completion of the exam I will receive a certificate for one continuing education unit from University of Wisconsin-Stout. Please start me with the next available issue (see program schedule below). My cost is $59, or $49 each for two or more to enroll.

With either CEU option, the enrollment fee includes a $23.95 one-year subscription to Early Childhood News magazine. If you already subscribe, your subscription will be extended for one additional year.

Names of Enrollee: (Please print name as you wish it to appear on certificate.)
NAME ________________________________________________________________
TITLE: __ 1. Owner __ 2. Director/Admn. __ 3. Teacher/Staff __ 4. Other
ADDRESS: _______________________________________________________________
CITY: _______________________________________ STATE: ________ ZIP: ________
PHONE: ____________ SS#: __________________

Program Schedule (check box of issues with which you would like to begin.)

Payment (All registrations must be prepaid.)
I have registered _____________ enrollees at $__________ each for a total of $ __________.

___ Check enclosed in the amount of $ ___________ payable to Early Childhood News.

___ Charge to: ___ MasterCard ___ Visa ___ Discover ___ American Express
Card Number _____________________________ Expiration Date ________________
Signature __________________________________________________

Name and phone number of person completing this form:
Name: ______________________________________ Phone: ________________________

Check the category that best describes your child care center:
__ 1. Independent __ 2. Chain/Franchise __ 3. Company/Employer
__ 4. Public/Private School __ 5. Church Affiliated __ 6. Head Start
__ 7. Military/Government __ 8. Family Day Care Home __ 0. Other

How many children are enrolled at your center?
__ 0. 1-49 __ 1. 50-74 __ 2. 75-100 __ 3. 101-200 __ 4. 200+

WEX27

This page last uptdated November 09, 1997