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Family Childcare Conference Registration Form

Name(Required)

First Last

Phone(Required)

Email(Required)

Please indicate your race

American Indian or Alaskan Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Please indicate your ethnicity

Hispanic or Latino

Not Hispanic or Latino

Education(Required)

Select all that apply

High School Diploma or GED

CDA

Some college, no degree yet

Associate degree

Bachelor's degree

Master's degree

Doctorate

Program Information

Program Name(Required)

What does your childcare call itself?

Your role(Required)

Owner/Operator

Staff

Do you participate in Paths to QUALITY?(Required)

Yes

No

No, but we are accredited

Select your current Paths to QUALITY level(Required)

Level 1

Level 2

Level 3

Level 4

Please provide your accreditations(Required)

Program Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Which county does this program reside in?(Required)

Does this program use a childcare management system?(Required)

Yes

No

What is the name of the childcare management system?

Examples include, Brightwheel or ProCare

Pay for your registration

Standard Registration Fee

Price:

Which days do you plan to attend?(Required)

This information is needed for headcounts, it will not impact your registration fee.

Friday Only

Saturday Only

Friday & Saturday

Hidden

Early Bird Discounts(Required)

Choose which days you're interested in participating. The following discounts will expire on January 14, 2023

Friday & Saturday

Saturday Only

How many people are you registering for?(Required)

Please enter a number from 1 to 10.

Please enter the name(s) of your guest(s) separated by a comma

Promo Code

Deco County Discount

Amount Due

Credit Card(Required)

Cardholder Name

Card Details

Address of credit card(Required)

Same as program address

Street Address Address Line 2 City State ZIP

Comments

This field is for validation purposes and should be left unchanged.

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Early Childhood Alliance
3800 N Anthony Blvd, Fort Wayne, IN 46805
(260) 745-2501 | Food Program: (260) 333-8290 | Fax: (260) 744-3473 | (800) 423-1498 | Emergency Hotline: (260) 579-4443
Office Hours: Mon-Thurs - 7:30am-5:30pm | Fri - 7:30am-11:30am

© Early Childhood Alliance

Early Childhood Alliance is a registered 501c3 non-profit organization, FID: 35-0953465.

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Admin Offices: 3800 N Anthony Blvd, Fort Wayne, IN 46805
Beacon Learning Center: 2125 Beacon St, Fort Wayne, IN 46805
Downtown Learning Center: 516 E Wayne St, Fort Wayne, IN 46802
Call Local: 260-745-2501
Call Toll Free: 800-423-1498
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