This document is a payment form for reviewing early childhood education self-learning modules. It requests the facility name, address, director name, title of the module being submitted, date submitted, number of participants, and lists of up to 10 participants. Payment of $10 per participant is due to the Pennsylvania Chapter of the American Academy of Pediatrics for review and credit upon successful completion of the module and submission of required documents.

1. ECELS/Healthy Child Care PA
Rose Tree Corporate Center II
1400 N. Providence Road, Suite 3007, Media, PA 19063
800/243-2357 (PA only), 484/446-3003, 484/446-3255(fax)
E-mail: ecels@paaap.org Website: www.ecels-healthychildcarepa.org
MODULE REVIEW PAYMENT FORM
Please include this payment form with each module to be reviewed along with your
check payable to the PA Chapter, American Academy of Pediatrics.
Facility Name:___________________________________________________
Site Address:____________________________________________________
____________________________________________________
Mailing Address:__________________________________________________
__________________________________________________
Director Name:__________________________________________________
Self-Learning Module Title:_________________________________________
Date Submitted:________________ Total # of participants @ $10.00________
Participants:
1. _______________________________________________
2. _______________________________________________
3. _______________________________________________
4. _______________________________________________
5. _______________________________________________
6. _______________________________________________
7. _______________________________________________
8. _______________________________________________
9. _______________________________________________
10. _______________________________________________
Credit will be issued upon successful completion and submission of all required documents to
ECELS and payment to PA Chapter, American Academy of Pediatrics.
(Please use additional sheet(s) if necessary)
5/30/13