Name: ___________________________                  

Child Care Address: ________________

_________________________________

_________________________________

Phone: ___________________________

Email: ___________________________

 

Circle One:      Licensed Family Home

                        Registered Family Home

                        Group Family Home

                        Child Care Center

                        Pre-school

                        Head Start

                        After-school Program

Date Program was established: ______

Birth Date (Month / Day) : ___________

Credentials Circle One: CDA

                                    Associate Degree

                                    Bachelor’s Degree

                 NAFCC / NAEYC Accreditation

 Cost is $15 per year