ESD 112 Child Care Resource and Referral: Provider Training Registration Form

Provider Training Registration Form

Name:

Phone:

Address:

City, State & Zip:

STARS Registry #:

Class/Workshop:

Date & Time:

Enclosed Fee $

Please print the form, fill it out, and mail to:

ESD 112 Child Care Resource and Referral
2500 NE 65th Avenue
Vancouver, WA 98661-6812