Membership Form : Get Involved

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 #

Visa MasterCard Discover

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