HeadsUp! Reading registration form

Name: _______________________________________________________________________________________

Agency/School: _______________________________________________________________________________

Address: _____________________________________________________________________________________

City/State/Zip/County: __________________________________________________________________________

Phone: (day)________________________________ (evening) __________________________________________

Fax: __________________________________ E-mail: ________________________________________________

My primary early childhood role is: (please check)

__ Family Child Care __ Center Child Care __ Head Start __ Kindergarten __ ESL Teacher

SITE YOU PREFER TO ATTEND:
Please refer to current site list at http://www.education.ne.gov/OEC/train/hur/sites.html or contact Mary Beth Pistillo at 402-557-6893 or marybeth.pistillo@nebraska.gov. You can also refer to your Early Learning Connection partner. Please visit the Early Learning Connection website at http://www.education.ne.gov/OEC/elc/elc_list.html.

Location: ___________________________________________________________________________________________

I WILL BE PARTICIPATING FOR: (please check one)

___ Inservice Hours

___ CEUs (available through NHSA)

___ College Credit (Name of institution): __________________________________________________

___ RULE 11 REQUIREMENTS

IMPORTANT INFORMATION:
1.	If you are interested in college credit, you must select a facilitated site. (Facilitated sites are identified on the current site list at http://www.education.ne.gov/OEC/train/hur/sites.html or call Mary Beth Pistillo at 402-557-6893.
2.	Please check the website for an up-to-date listing of participating colleges.
3.	There is no charge for participating in HeadsUp! Reading.
4.	Fees for obtaining college credit are arranged through the individual institutions and are the responsibility of the participant.
5.	CEUs will be obtained through the National Head Start Association. NHSA fees are the responsibility of the participant electing to obtain CEUs in this way.
6.	Colleges offering the course for credit will make books available through their bookstores or participants may order on their own from the publishers.

Return this form to the facilitator of the site/sites that you will be attending!