2023-2024 Caswell County Partnership for Children Child Care Training Registration Form

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All information is required. Complete one form per person. If you need assistance filling out the form, contact Bridget Bernal at 336-694-1538 or ccpfcbbernal@esinc.net.

Training Participant Information:

Name: *

Phone Number: *

Email (Each person who registers for a training must provide their own individual email address to receive updates, training links, etc.): *

Name of Child Care Facility Employed: *

County where the Child Care Facility is located: *

Caswell

Other:

Check the box for your Position/Title: *

Director

Assistant Director

Program Coordinator

School Age Group Leader

Family Child Care Home Provider

Lead Teacher

Substitute

Other:

How many kids are in your classroom for the Age Group Birth to Three or 0-36 months? Please provide a number: *

How many kids are in your classroom for the Age Group Three to Five or 36-60 months? Please provide a number: *

How many kids are in your classroom for the Age Group Five and Older or 60 months to 12 years? Please provide a number: *

Check the box for your age range: *

15-19 years

20-24 years

25-34 years

35-44 years

45-54 years

55-59 years

60-64 years

65 and over

Prefer not to give

Check the box for your ethnicity: *

Hispanic or Latino

Non-Hispanic or Latino

Prefer not to give

Check the box for your Race: *

African American

Asian

Caucasian

Multi-Racial

Native-American

Other

Prefer not to give or Unknown

Check the box for your Gender: *

Female

Male

Prefer not to give

Training Information: Check the training title(s) you would like to attend: *

Option 1

Required

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