Home-Based Child Care Training Program Registration

First Name*

Last Name*

Preferred Name

Other/Previous Name (which may appear on records)

Birthdate*

Email*

Phone*

Mailing Address:

Street*

City*

State*

Zip Code*

County Residence*

Sex Assigned at Birth*

Gender Identity (optional)

Country of Citizenship*

Education Data *

Do you have 2 years of experience in child care? *(Experience includes parenting, babysitting, and/or early childhood education.)

Have you completed the NYS Division of Child Care Services Child Day Care Orientation?*(This is a 2-hour online course, and is not a program information session)

Have you requested an Office of Children and Family Services (OCFS) Application from NYS?

How did you hear about this program?

Have you ever taken a JCC class?

Photo Consent

Jefferson Community College may obtain photos during training for promotional and public relations purposes. If you do not wish to be featured in photos, please email marketing@sunyjefferson.edu.