Southern IL Chapter - Early Childhood Expo at SIC

Sat, March 2, 20199:00 AM - 3:00 PM


PARTICPANT REGISTRATION FORM


The Exhibit Area (SIC cafeteria) will open at 7:30 am on Saturday morning for exhibitors to set up.

We will open to participants at 9:00 am.  Exhibits open from 9:00 to 10:00 a.m. 


SIC ECE EXPO 


ONLY Checks or Money Orders will be accepted.  Cost - $15.00 


Make checks/purchase orders payable to: SIC EARLY CHILDHOOD CLUB


Mail check to:Dr. Diane King

Southeastern Illinois College

3575 College Road

Harrisburg, IL  62946


Checks must accompany Registration Forms. One form per participant. Make additional copies.


PAID REGISTRATIONS MUST BE RECEIVED BY WEDNESDAY, FEBRUARY 13, 2019.


PLEASE PRINT LEGIBLY IN BLACK INK OR TYPE.

Name _____________________________________________

Home Address ______________________________________ 

Home/Cell Phone ___________________________________

*Email ____________________________________________
(*Confirmation will be sent via email.)

◻ Will donate gift basket


Place of Employment (Name, address, phone)

_________________________________________________________________________


Position ________________________________________________ (specify age group if applicable)


NAEYC Member?     Yes ___   (Chapter Name   ____________ ID# __________) No _______


SI Chapter ILAEYC Member?    Yes ___________    No __________

ECE Student – Name of College:  _______________________ High School Student – Name of High School _____________________

ECE Degree Program:  AAS____ AA/AS_____    BA_______      MA___________

Other:  Please specify   ____________________________________ 

GATEWAYS REGISTRY NUMBER ________________________________   (N/A ________)

Gateways Credentials – Please check all that apply:     (N/A __________)

ECE Level 2 ___   ECE Level 3___ ECE Level 4 ___   ECE Level 5 ____    

IT 2___ IT 3___   IT 4___   IT 5 ___ 

IDC I     ___    IDC II ___   IDC III ____   Family Child Care ___   Other ___________ (specify)

ExceleRate – Gold _______   Silver _______   Bronze ________ Green _________