Membership Form : Get Involved : Child Care Resources of Rockland

Please check the appropriate category:

Individual/Family Child Care Provider: $45.00
Group Family Child Care Provider: $55 - for provider and 1 assistant, and $12 for each additional staff. Please provide a separate sheet with names of all staff members included in membership.
Center-Based Child Care Provider: $60 for 1-5 Staff ($12 for each additional staff member, not to exceed $400) Please provide a separate sheet with names of all staff members included in membership.

Additional Staff Members

Select the appropriate number from the pulldown menu.

Organization:

Enter N/A if not applicable

First Name:

Last Name:

Phone:

Address line 1:

City:

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State:

Zip Code:

Cardholder Name

Credit Card #

Expiration Date

Security Code

Billing Zip Code

Your total payment will be .

Your credit balance will cover

Your credit card will be charged

Your bank account will be charged

Get Involved