CDA Training
Registration Form
Althea Penn, m.ed.adm., Educational Consultant
Please print and complete all information.
STUDENT NAME: ___________________________________________________________________________
Social Security Number (Last four digits): ___________________________ Date of Birth: ___________________________
STREET ADDRESS:________________________________________________________ CITY ____________________
ZIP _________ PHONE NUMBER:_____________________________ FAX NUMBER:_______________________________
E-MAIL ________________________________________
EMPLOYER NAME: ___________________________________________________________________________
SUPERVISOR NAME: _______________________________________ TELEPHONE: _______________________________
STREET ADDRESS:________________________________________________________________ CITY _______________
ZIP _________ PHONE NUMBER:_____________________________ FAX NUMBER:________________________________
WEBSITE ________________________________________________________
Type of Center: SCHOOL/Center ___ Group Day Care ___ Family Day Care___
Registration $375.00 X # of Participants $____________ = $______________________
Please sign below after reading the following important information:
Registration payment must be received with this form except when paying by credit card.
Make checks payable to Penn Consulting and mail to: Penn Consulting P. O. Box 49254 Atlanta, GA 30359
We accept Visa and MasterCard. Credit card information:
# ________________________________________________________ Visa ___ MasterCard ___
Expiration date: ______________________ CVC No. (on back of card) _____________________
Authorized Signature _______________________________________ Date ________________________
Please note there is 3% processing fee for credit card payments. Please ensure the name and zip code above match the credit card billing information. This may delay processing.
Cancellations/Substitutions: If you cancel your registration up to ten business days before the course begins, your registration fee will be refunded less a $30 service charge. Cancellations and substitutions must be made in writing (email acceptable). Registration may be transferred to a later session date once.
Withdrawal: Child development instructors may choose to withdraw a student if the student does not meet the course requirements. Students are urged to consult with their instructor or an advisor before making schedule changes. A student is not eligible for any refund if (1) the student fails to formally withdraw in writing; (2) the student is suspended for disciplinary reasons; (3) the student resigns when a disciplinary action or honor code violation is suspected (including plagarism).
Tax Deduction: The expenses incurred for ongoing professional development are tax deductible, when completed to maintain or improve professional skills. Your accountant can provide details.
Questions? Contact Althea at 678.557.8684 or penntraining@yahoo.com
Signature ___________________________________ Date _____________ Check or m.o. # ____________________