Training Registration Form
Use this form to register for one of our upcoming training events. To register for FREE events Click Here.
*First Name:
*Last Name:
*Address:
*City:
*State:
*Zip Code:
*Date of Birth:
*Last 5 Digits of Social Security #:
EEC PQ Registry ID # (required)
Register on-line at https://www.eec.state.ma.us/PQRegistry/
*Phone:
Email:
Employer:
Location:
Work Phone:
Fax:
Position:
*Please choose at least one of the following that applies to your position. Select at Least One Family Child Care Group Child Care: Infant/Toddler Group Child Care: Preschool Group Child Care: School Age Public School Parent Other
Do you have a college degree?
No Yes
If Yes, type of degree: Select One Associates Bachelors Masters Doctorate
Are you enrolled in college?
Are you pursuing EEC qualifications? (i.e. Teacher, Lead Teacher, Director) No Yes
*Course/Workshop Title:
*Course Number:
*Date (s):
*Fee:
Course/Workshop Title:
Course Number:
Date (s):
Fee:
Registration Options:
If you would like to receive a registration confirmation please email us at mail@cccfscm.org. Registration accepted with payment only.
1. By credit card (Note: This is not a secure form)
* Select Credit Card type Visa Master Card
*Card #:
*Name as it appears on card:
*Address of card holder:
*Expiration Date:
*3 Digit Security Code: Located on the back of your credit card.
2. By check or money order, print and mail registration form and payment to:
3. By fax, print and fax form to 508-791-4755 with credit card information filled out.
4. Drop In to Center for Childcare Careers address above.
Thank you for taking the time to complete this form. Please click the Submit button if you are paying by Credit Card. Submission of this form does not guarantee enrollment. If you are paying by check, print out this form and mail it to us with your payment. Registration accepted with payment only.
