UMass Amherst

Registration Survey

To register, complete the survey below and submit your answers by clicking the SUBMIT button at the end.

You must complete this form with a correct email address to receive your enrollment key and course access directions.

Welcome to Food Safety for Family Day Care Providers. Please take a few minutes to answer all of the following questions. All of your responses are confidential. Thank you!

Important: Please enter your name, address, and email here so we may send you the enrollment key to access the course pages and other materials. A valid email address is needed.

If you need to cancel the course there will be a $5 service fee for processing.

Part 1. About You.

First Name:

Last Name:

Address:

Town/City:

State:

Zip Code:

Telephone:

Fax:

Email:

Confirm Email:

Please check the most appropriate response.

1. Your age range:

21 and under

22-39

40-64 65 and up

2. I have completed grades in school, including high school, years in college.

Part 2. Please provide the following information about your day care program.

3. Number of years (approximately) as a family child care provider:

4. Number of meals served each week ; Snacks served each week

5. On average, number of children in your care each week

6. I participate in the Child and Adult Care Food Program.
Yes
No

Part 3. Payment

I would like to enroll in

the course that begins on April 28, 2010

Due to new state laws regarding transmission of personal information online, the university has implemented new policies that prevent us from being able to accept payment information online at this time. After submitting this form, please call us at 413-545-1908 and provide us with the following information:
Full Name
Credit Card type (visa mastercard, american express, etc)
Credit Card Number
Credit Card Expiration date
Security code on the back of the card

You may also submit this information by mail. Our mailing address is:
Food Safety Course
STEM Education Institute
229 Hasbrouck Lab
University of Massachusetts
Amherst, MA 01003

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