Application to Join Association

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

For All your child care forms go to https://health.mo.gov/safety/childcare/forms.php