Child Care Health Consultant Enrollment Form

Health Care Consultant Enrollment Form

Please complete all applicable fields on the form below. Press the 'submit enrollment form' button at the bottom of the form, and your enrollment form will be placed under review. If you would rather complete the paper form, you can retrieve it here. You will need adobe acrobat reader in order to view and print it.

Once you submit your enrollment form, you will be sent to a confirmation page. If you wish to return to the previous page without completing the form, click the grey 'x' in the upper or lower right hand corner of this enrollment form.

Anything marked with a red asterisk * is required:

Last Name: *

First Name : *

Organization Name :

Address: *

Address (Suppl):

City: *

State: *

Zip: *

Phone: *

Fax:

Email Address :

County: *

If you are a medical student, intern or resident, please indicate which you are using the drop-down box below. Then put your estimated completion date in the box provided. If this is not applicable to you, please choose 'Not Applicable' from the drop-down box, and leave the date field blank.

Estimated Date of Completion:

Complete Either 'Section A' Or 'Section B' Below:

If there IS an early childhood program with which you would like to be linked, please complete the following section. Provide as much information as you can.

Name of Program: *
Contact Name:
Phone:
County: *

If there IS NOT an early childhood program with which you would like to be linked, please complete the following. Place a number in front of the appropriate program (For instance, if you would like to be linked with 2 starting points centers, you would place a '2' in the box next to 'starting points center').

	Licensed Child Care Center	Starting Points Center
	Regulated Family Facility (7 - 12 children)	Certified Home Care (1 - 6 children)
	Head Start/Early Head Start Program	No Preference

I am interested in (check all that apply):

	Receiving regular updates via a listserve

Once you have verified all of the above information, press the 'submit enrollment form' button below.