6/24/23 Outdoor Adventures: Intentional Outdoor Play

Personal Information

• * First Name:
• * Last Name:
• * Email Address:
• * Confirm Email Address:
• * Address 1:
• Address 2:
• * City:
• * County
• * State: --Choose-- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia 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 -------------- Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory
• * ZIP Code:
• * Phone:
• Cell Phone:
• Please enter your Gateways ID:

• Will interpretation services be needed?

  • Yes
  • No

• Promo Code

  Enter Code: Apply

• Fee

  Type	Fee
  Event fee	$45.00

Business Information

• *

  Please complete business information if different from above

  • Same as above
  • Different business information(listed below)
• Center/Business Name
• Address 1:
• Address 2:
• City:
• State: --Choose-- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia 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 -------------- Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory
• ZIP Code:
• Phone:
• County:

Program / Position Information

• * What is your licensing status? --Choose-- License-exempt Licensed by DCFS Not applicable
• * Do you currently serve children on the Child Care Assistance Program --Choose-- Yes No
• * What is your position title? --Choose-- Kith and Kin(not licensed, caring for children of family or friends) Potential Child Care Provider Independent Consultant Family Child Care Owner Family Child Care Assistant Center Director Center Assistant Director Center Teacher
• * Number of years in your current position --Choose-- Less than 6 months 6-12 months 1-3 years More than 3 years
• Center Child Care staff - Ages of children you personally provide care for. (This should be the PRIMARY age you provide care for). --Choose-- Infants Toddlers(15-23 months) 2 years Preschool School-age None (Director/Admin)

• Family Child Care staff - Ages of children you provide care for. (Check all that apply).

  • Infants
  • Toddlers (15-23 months)
  • 2 Years
  • Preschool
  • School age
• * Is your program listed on our database? --Choose-- Yes No Not sure

• Registrant consents to the use without additional authorization or compensation of his/her image, likeness, actions and/or statements incidental to any live or recorded photographic, audio or video displays, broadcasts or other transmissions, exhibitions, publications or reproductions made of or at the Event.

Participant Information

You may add a maximum of 10