the registration form

A CareGiver Network
www.acaregivernetwork.com
720-870-1161
Course Schedule & Registration Form
Must pre-register and pre-pay for all classes. No walk in’s or paying at class permitted so classes start on time. Space limited.
All classes are taught in English. You may bring your own translator, but you must understand the course content to receive a certificate.
CLASS LOCATIONS: Be on time!
o
#1 - Pre-licensing Classes: 6436 S. Racine Circle Centennial, CO 80111
Main door locks automatically evenings and weekends.
Someone will be there to open the door 10 minutes before class starts.
Bring a sack lunch. There is a microwave and refrigerator for your use.
o
#2 - CPR/First Aid, Medication Admin.& Universal Precautions classes held at St. Martin in the Field Episcopal Church,
4740 S. Buckley Road, Aurora, CO 80015
Students who miss 20 minutes of class or more will not be issued a certificate of training. No refunds.
Returned check fee - $30 per check.
o
If you check is returned NSF and you do not make good on your checks: the certificate will become invalid and reported to
Human Services or the appropriate authority and turned over to the county district attorney’s office for collection.
Please fill out the form below with all of the information in case we need to cancel or reschedule the class for any reason..
Contact person : Darlisa Lorentz # 303-680-8618 or [email protected]
CPR & FIRST AID– 8:45 a.m. – 1:00 p.m. Held on the 3rd Saturday of selected months. Must pre-register and pre-pay. Space
limited. Note: Location #2
Class date signed up for __________________
MEDICATION ADMINISTRATION – 8:00 a.m. – 12:00 p.m. Held on the 2nd Saturday of selected months. Must pre-register and
pre-pay. Late enrollments will be contacted for the next class. *NOTE: Don’t be late. Must attend entire class for certificate. Location
#2.
Class date signed up for ____________________
UNIVERSAL PRECAUTIONS – 12:15 p.m. – 2:00 p.m. Held on the 2nd Saturday of selected months. Must pre-register and pre-pay.
Space limited. *NOTE: Location #2. Be on time.
Class date signed up for: __________________
FAMILY CHILDCARE PRE-LICENSING -- See course schedule for dates/times. *NOTE: Location #1. Test and homework required,
assignments available online prior to class. Pass with 80% or better. Course cannot be split over two different months.
Class dates/times signed up for: 1st date: ____________ Times:____________
2nd date: ___________ Times:____________
Total amount paid: ___________
Check # ___________
Purchase classes online with PayPal
◊ Please save the top portion of this form for your receipt – Class confirmations are not sent.
Training Registration Form
Name ________________________________ Address ______________________________________________________
(include all names/nicknames you go by; ie. Single, married, formal, shortened, or nicknames of first & last names)
City __________________________________ Zip _______________ Telephone # ________________________________
(includes course book.)
2nd half of FCC
FCC Pre-Licensing
Packet from State
Forms Ctr. (optional)
Oct
Nov
X
20
18
15
26
17
21
8:45 am – 1:00 pm
$45
X
13
-
8
12
10
14
8:00 am – 12:00 pm
$45
X
13
-
8
12
10
14
12:15 pm – 2:00 pm
$15
8:00 am - 5:30 pm
$75
5/30
&
7/25
&
--
9/26
&
10/
31
&
-&
6/6
8/1
--
10/3
11/7
--
X
Dec
Sept
US$
Aug
Time
July
CPR/FA
Medication
Administration
Universal Precautions
(U.P.)
Family Childcare PreLicensing (FCC)
RQRD
for FCC
License
June
2015 Classes
QTY
Fax # _____________________ Email ____________________________________________________________________
12/
5
&
12/
12
8:00 am - 2:30 pm
$18 – in class
$22 – by mail
Make check payable and mail to: A CareGiver Network, P.O. Box 460861, Aurora, CO 80046-0861
Amt
Paid