Membership Application |
Individual Membership is ONLY $25.00 per year...
Name:__________________________________ |
County:________________________________ |
Program Name:___________________________ |
Star Rating:____________________________ |
Address:________________________________ |
Email:_________________________________ |
City:____________________________________ |
State:_______ Zip:______________ |
Telephone: (___)__________________________ |
Fax: (___)_____________________________ |
Job Title:________________________________ |
Years of Education:______________________ |
Do you belong to a local child care association? |
Yes_____ or No_____ |
Name of Group:___________________________ |
Contact Person:_________________________ |
Check the one that best describes your child care program or agency: |
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| ____Private tax paying center | ____Private non-profit center | ____Family Child Care Home |
| ____Employer operated center | ____County operated center | ____Church/Synagogue center |
| ____Head Start | ____State Government | ____ Resource/Referral Agency |
| ____University/College | ____Parent | ____Advocacy Organization |
Check your three top areas of interest: |
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| ____Voice in Public Policy | ____Professional Development | ____Newsletter |
| ____Networking | ____Membership | ____Conferences |
Circle annual membership type and mark amount enclosed: |
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| $25.00 Individual | ||
Champions
for Children Memberships |
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| $_____ Silver Champion | $_____ Gold Champion | $_____ Platinum Champion |
| $225 to $349 | $350 to $574 | $575 to $15,000 |
$200.00 Contributing Vendor
$______ I would like to make a donation to support NCECA's legislative efforts
$________ Total Enclosed
Mail payment and form to NCECA, PO Box 4292, Chapel Hill, NC, 27515
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