Name ___________________________________________ Date ________

Street Address ___________________________________

City _________________________ State _____ Zip Code ___________

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

Character References (no family members please), but people that have
Name  ________________________ Name ______________________
Phone #  _____________________ Phone # ______________________
To do a background check we need your:
Social Security #___________________ and Birthday _________

Tell us why you think you are or would make a Good Child Care Provider: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
​Your Elementary School District ____________________________
Do you care for children now? _____  How Many? _____ 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 hours are you willing to work? ________ What days of the week are you willing to work? ________ 

Please send 50.00 dollars along with your membership application to:
Cindy Harris
Blue Springs Child Care Association
410 SW Greystone Drive
Grain Valley, Mo.64029