DEI Registration – Early Childhood Consumer Education and Technical Assistance Center

Name of Center *

Phone Number *

Pick which Cohort your program will be attending *

Staff Registration

Please register each of your staff that will be attending the DEI Training. If you have more staff than slots availble please submit this form and go back and fill out another form untill all your staff have been registed.

1. Name *

First

Last

Which of the following best describe area of development?

Email *

Birth Date *

Last 4 digits of SS number *

2. Name

First

Last

Which of the following best describe area of development? (copy)

Staff's Email

Birthdate

Last 4 digits of SS Number

Next Staff Member

3. Name

First

Last

Which of the following best describe area of development?

Staff's Email

Birthdate

Last 4 digits of SS Number

Next Staff Member

4. Name

First

Last

Which of the following best describe area of development?

Staff's Email

Birthdate

Last 4 digits of SS Number

Next Staff Member

5. Name

First

Last

Which of the following best describe area of development?

Staff's Email

Birthdate

Last 4 digits of SS Number

Next Staff Member

6. Name

First

Last

Which of the following best describe area of development?

Staff's Email

Birthdate

Last 4 digits of SS Number

Next Staff Member

7. Name

First

Last

Which of the following best describe area of development?

Staff's Email

Birthdate

Last 4 digits of SS Number

Next Staff Member

8. Name

First

Last

Which of the following best describe area of development?

Staff's Email

Birthdate

Last 4 digits of SS Number

Next Staff Member

9. Name

First

Last

Which of the following best describe area of development?

Staff's Email

Birthdate

Last 4 digits of SS Number

Next Staff Member

10. Name

First

Last

Which of the following best describe area of development?

Staff's Email

Birthdate

Last 4 digits of SS Number

Next Staff Member

11. Name

First

Last

Which of the following best describe area of development?

Staff's Email

Birthdate

Last 4 digits of SS Number

Next Staff Member

12. Name

First

Last

Which of the following best describe area of development?

Staff's Email

Birthdate

Last 4 digits of SS Number

Next Staff Member

13. Name

First

Last

Which of the following best describe area of development?

Staff's Email

Birthdate

Last 4 digits of SS Number

Next Staff Member

14. Name

First

Last

Which of the following best describe area of development?

Staff's Email

Birthdate

Last 4 digits of SS Number

Next Staff Member

15. Name

First

Last

Which of the following best describe area of development?

Staff's Email

Birthdate

Last 4 digits of SS Number