Name ___________________________________________ Date ________
Street Address ___________________________________
City _________________________ State _____ Zip Code ___________
Home Phone __________________ Cell Phone _____________________
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
Please send 75.00 dollars along with your membership application to:
Blue Springs Child Care Association
3605 N.W. Valley View Pl.
Blue Springs, Mo.64015