Name of organization:

Contact Person/Title:

Address:

City: State: Zip:

Phone #:    Fax#:

Email: Website:

Who is your target audience for these workshops? (check more than one if applicable):

Center-based providers  Home-based providers

Teachers                         Parents

Other  

Tell us about the children & adults served by your organization (if applicable):

Number of children served   

Ages of children served   

Number of parents served   

Number of teachers/child care providers in center   

Tell us about the characteristics of the population who will attend these workshops: