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Genesee Valley BOCES
SSSC Certification Course Registration Form
12/4/2022
 Certification Course Registration
 
  Registrations are addressed in the order in which they are received. Please know that high volume may delay completing your payment transaction and emailing your login information.  We do our best to serve each individual as soon as possible.  Thank you for your patience. 
 

Registrant Information

 

 
First Name: *
Last Name: *
Title:
School District:
School Building:
Address: *
Street
*
City
*
State
*
Zip Code
E-mail: *
Phone: *()- Ext.
Fax: ()- Ext.

____________________________________________________________________________

 

Course Selection

*
Child Abuse Identification and Reporting $30.00  
Dignity Act (DASA) $80.00  
School Violence Prevention and Intervention (SAVE) $30.00  
 
Please complete the information below if you would like CTLE Credit Hours (which are for professional certified teachers, administrators and Level III teaching assistants)
Date of Birth (mm/dd/yyyy):
Last 4 digits of Social Security Number:

____________________________________________________________________________

 
Payment Information
 

Course login information will be emailed after payment transaction is completed.

  

Payment: *
Purchase Order (please add PO # in comments box)  
Payment through BOCES Coser (GVEP component districts. Forms will be mailed to district for signatures)  
Payment Through Cross Contract (non-GVEP component districts)  
SSS Center Use Only  
Credit Card (please fill out all information below. An additional $3.00 transaction fee will be added)  
Card Type::
Visa  MasterCard  Discover  
Name as it appears on card::
Billing Address:
Street

City

State

Zip Code
16 Digit Card Number::
Expiration Month/Year (xx/xx)::
Security Code on back of card:
Comments:


For routing purposes please use your full name and work e-mail in the space below.

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Your Name:*
Your E-mail:*
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Your Routing Level: (Please refer to routing instructions)
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Verification Code:*
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