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

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