Name ___________________________________________ Date ________

Street Address ___________________________________

City _________________________ State _____ Zip Code ___________

 Home Phone  __________________ Cell Phone  _____________________  
​ E-mail _________________________________
 Name of your daycare ________________________________
 ​Are you State Licensed  _____ 
 Are you State Contracted _____ 
 (You do not have to be State Licensed to join our Association)

​Your Elementary School District ____________________________
 Do you care for children now? _____   What ages?  _____ How many children would you like to care for? _______ Do you or would you consider caring for Special Needs Children? ________
 Are you CPR/FirstAid Certified?  ___________ What are your hours of operation? ________ What days of the week are you open?
______Would you like your address on Web site
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 Please send 75.00 dollars along with your membership application to: 
Debbie Clark
 Blue Springs Child Care Association
 3605 N.W. Valley View Pl.
 Blue Springs, Mo.64015

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