Home-Based Child Care Training Program Interest Form

If you see this don't fill out this input box.

First Name*

Last Name*

Birthdate*

Email*

Phone*

Sex Assigned at Birth* Please Select Male Female

Gender Identity Please Select Male Female X Transgender Male Transgender Female Gender Non-Conforming/Non-Binary Not sure/Questioning Other(optional)

Mailing Address:

Street*

City*

State* Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip Code*

County Residence* Please Select Lewis Jefferson Other

Do you have 2 years of experience in child care? * Please Select Yes No(Experience includes parenting, babysitting, and/or early childhood education.)

Have you completed the NYS Division of Child Care Services Child Day Care Orientation?* Please Select Yes No I'm not sure(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? Please Select Yes No I'm not sure

How did you hear about this program?

Have you ever taken a JCC class? Please Select Yes No

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