Call C a for or Presenters Presenters

Sat rd y M Saturday, March c 8 C nt a C mm n ty C rc Central Community Church

Thank a k you o again for agreeing to be a presenter at the Child Start fundraiser, Growing With h Children! h d n I have v attached other t h forms you need to fill out and send back to me; as well as helpful information and n o e opportunities to be involved. p Please return these forms as soon as possible and no later than the end of October. Please feel free to contact me at any time through the email or the phone if you have questions about the form or anything else. Again thank you for participating and I look forward to meeting you in person on March 8th. Sincerely,

Mary Reasoner Quality Outreach Specialist Child Start mreasoner@childstart org 316-682-1853 ext. 2291

Call C a for for Presenters Presenters

S tu day M Saturday, March ar h 8 Cen ra Community Commun y Church Chu ch Central

Presenter Form P res ente r F orm

Training Title: ____________________________________________________________________________ Presenter Name: ___________________________________________________________________________ Organization: _______________________________________________________________________ Street Address: __________________________________________ City: ________________ Zip: ________ Phone Number: _____________________________ Fax Number: __________________________________ Email: ___________________________________________________________________________________ Lunch Option: Regular Vegitarian No Lunch 2nd Presenter: _________________________ Lunch Option: Audio/Visual Needs Bringing my own Projector Screen Laptop Speakers White Board * Limited availability on the above items. We will let you know if an item is or is not available. All PCs are Windows based. No connections for Apple products. Must bring own. Evaluation Questions (See FAQ) 1. Need to Borrow* Submission Checklist This form KDHE Application - If not previously approved for in-service through Child Start W-9 Form Exhibitor Form - If applicable Advertising Form - if applicable Payment - if applicable Mail and/or email the above items to: Mary Reasoner mreasoner@childstart.org Child Start 1002 S. Oliver Wichita, KS 67218 Regular Vegitarian No Lunch

2.

Call C a for for Presenters Presenters

Saturday, S tu day M March ar h 8 C en ra C ommun y C hu ch Central Community Church

Q&A

Presenter P esenter Information nformat o

Where is Growing With Children? 6100 W. Maple Wichita, KS

What are all these forms? These forms are critical to ensure your training is approved for in-service and/or to be paid. If your training is already approved, then you will not need to complete as many forms. There are also forms for advertising and exhibits to complete if you are interested. Discounts MAY be available. Do you make copies? We request that you make copies on your own. However, if it will be difficult for you to make copies, please make an appointment with Mary before March 1 for assistance. How many people will be in my class? The classrooms we have reserved seat anywhere from 45-100+. We will not know which room you will be in until a few weeks out from the conference. Please check in with us at that time and we can give current and max capacities. Do you help with the cost of supplies? Unfortunately, we are unable to help with the cost of supplies. Growing With Children is Child Starts CCR&R annual fundriaser. Do I get free lunch? We offer all of our presenters lunch. Please make sure to let us know what type of meal(s) you need or if you will not be eating. What time do I need to arrive? After receiving your forms, you will receive more information about what session you will be presenting and what time to arrive. What if I need Audio/Visual (AV) Child Start has several projectors and laptops (Windows) available for use on a first come first served basis. We encourage everyone who has their own equipment to use it. You will be notified if we have the AV equipment you request. Please note, none of our projectors have Mac connections. Where do we enter to check in?
Presenters will enter through the areas highlighted orange

CCL.038 8/2011

Kansas Department of Health and Environment Bureau of Child Care and Health Facilities Child Care Licensing Program 1000 SW Jackson Street, Suite 200 Topeka, KS 66612-1274 Phone: 785-296-1270 Fax: 785-296-0803 Website: www.kdheks.gov/kidsnet REQUEST FOR IN-SERVICE TRAINING APPROVAL FOR CLOCK HOURS

To obtain clock hour approval, complete all information on this form, including required attachments (agenda, syllabus, handouts, presentation, etc), at least three months prior to the scheduled training date. Applications that are submitted with less time prior to the training date are not guaranteed to receive approval prior to the training date. Complete a separate application for each learning activity. Do not submit requests for training that has been approved for Early Childhood CEUs. Please print or type all information. Incomplete applications will be returned.

Sponsoring Agency/Organization Information

_____________________________________________ Name of Sponsoring Agency

Child Start, Inc

1002 S. Oliver ____________________________________________ Address of Sponsoring Agency

Wichita 67218 SG ____________________________________________
City Zip County

316 316 682-1853 (______)__________________(______)____________ Telephone Fax

689-8713

Marilee Haney ____________________________________________ Contact Person

Instructor/Trainer Information

mhaney@childstart.org ____________________________________________ E-mail

Instructor: First and Last Name

Co-Instructor/Trainer: First and Last Name

Current Employer

Current Employer

Job Title

Job Title

Address

Address

City ( )

State ( Fax )

Zip

City ( )

State ( Fax )

Zip

Telephone

Telephone

Email

Email

Degree/Certificate/Credential ( if any)

Degree/Certificate/Credential ( if any)

Professional Experience Relevant to Topic

Professional Experience Relevant to Topic

Learning Activity/Training Information Title of the learning activity/training ___________________________________________________________________ Method of Delivery (if online, provide link to training site/material) ______ Classroom Online training site Online Both

Was the learning activity previously approved by KDHE for child care/school age program in-service training?
_______ Yes _______No

If yes, note that training is approved for a period of 5 years and does not need to be re-submitted for review unless; o there is a significant change in the content of the training including alteration of the objectives o there is a change in primary instructor/trainer (change of co-instructor/trainer does not require resubmission) o there is a change in the title of the learning activity o there is a significant change in the length of the training (30 minutes or less does not require re-submission although approved training may NOT fall below one hour of total contact time) but more than 30 minutes does require resubmission along with explanation of the added content)
Enter the approved course number ________________________________________________________________
Child Start, Inc. Name of the Sponsoring Agency _____________________________________________________________________________

The training is being re-submitted because_____________________________________________________________________ Scheduled date(s) ________________________________________________________________________________

Enter repeated activity if this learning activity is offered on an on-going basis Scheduled locations(s) ______________________________________________________________________________________ Enter general service delivery area if this learning activity is offered on an on-going basis. For example, enter the counties or specify northeast Kansas if the service delivery area is regional ; enter state wide, if the service delivery area is anywhere in the state.

Course Schedule: Enter the course schedule in terms of the time, activity and the related instruction method.

Beginning Time

Ending Time

Learning Activity

Instruction Method

Sample: 9:00 am

10:30 am

Milestones in Infant Development

Lecture & Small Group Work

10:30 am

10:45 am

Break

Brief Description of Training including the objectives (may include additional information on the back or attach pages): Objectives:

Description:

Specify the target audience (check all that apply): ______ licensed day care home/group day care home provider and staff ______ center based staff ______ infant ______ toddler ______ school age ______ preschool ______ center based administration/program director ______ licensing survey/licensing director ______ other _____________________________________________________________________________________

Please check one content area relating to the primary objective of the learning activity using the Core Competencies for Early Care and Education Professional in Kansas and Missouri: ______ Child Growth & Development ______ Child Observation and Assessment ______ Health, Safety, and Nutrition ______ Program Planning and Development ______ Learning Environment and Curriculum ______ Families and Communities ______ Interactions with Children ______ Professional Development and Leadership

Check the knowledge or Skill Level of the Target Audience: ______ Level 1 skills or knowledge expected of an early care and education professional new to the child care field, with minimal specialized education and training. ______ Level 2 includes level 1 plus skills or knowledge commensurate with DCA credential in Child Development or equivalent education or training. ______ Level 3 includes level 1 and 2 plus skill or knowledge commensurate with an associates degree in early childhood or child development. ______ Level 4 includes levels 1,2, and 3 plus skills o knowledge commensurate with bachelors degree in early childhood or child development. ______ Level 5 includes levels 1,2,3 and 4 plus skills or knowledge commensurate with an advanced degree in early childhood or child development, understanding that at this level early card and education professionals are increasingly specialized. Check the method used to determine learner competency:

 No Determination ______Exam/Test ______

Other

______ Observation of Skills

______ Project Review

Assurances: 1) As the sponsor and/or trainer of the learning activity/training. I am responsible for the quality of the learning activity/training, qualifications of the instructors/trainers, supervision and documentation of the content and clock hour certificates for learners. 2) As the sponsor and/or the trainer of the leaning activity/training, I understand that the training content must not be in conflict with Kansas child care statutes and regulations. 3) As the sponsor and/or trainer of the learning activity/training, I will allow the Kansas Department of Health and Environment (KDHE), Child Care Licensing Program access to my documentation of approved learning activities. 4) As the sponsor and/or the trainer of the learning activities/training, I will not advertise that learning activities are approved by KDHE prior to obtaining written approval. I may advertise and approval has been requested. 5) As the sponsor and/or the trainer of the learning activity/training, I will be responsible for assuring that Certificates of Completion documenting attendance will not be issued to learners who have not completed the learning activity/training. Certificates are not to be awarded for partial attendance.

_____________________________________________________________ Signature of the Authorized Representative for the Sponsoring Agency

____________________________ Date (MM/DD/YYY)

_____________________________________________________________ Signature of Instructor/Trainer

____________________________ Date (MM/DD/YYY)

_____________________________________________________________ Signature of Instructor/Trainer

____________________________ Date (MM/DD/YYY)