If
you operate more than one Child
Care Center,
please reproduce this form, fill out a membership application and center
profile for each Center, and mail them as a group. Please include all centers under common
ownership. TOTAL NUMBER OF ALL CENTERS IN YOUR ORGANIZATION
_______ LICENSED CAPACITY OF THIS CENTER: ______ FOR PROFIT: ____
NON-PROFIT: ______ DATE:
___________________________________________________________________ NAME:
___________________________________________________________________ TITLE:
___________________________________________________________________ NAME OF CENTER:
________________________________________________________ STREET:
_________________________________________________________________ P. O. BOX (if applicable):
______________________________________________________ CITY:______________________________________________________________________________________ STATE: ____________ ZIP CODE: _______________ COUNTY: ________________ WORK PHONE: ______________________________ FAX: _______________________ EMAIL:
___________________________________________________________________MARYLAND STATE CHILD CARE ASSOCIATION
2008
Membership Application & Center Profile
OWNER’S NAME & ADDRESS (if different from above) ______________________________________________________________________________________ ______________________________________________________________________________________ 2008 Membership Dues MSCCA Membership = Licensed
capacity (slots) x $2.40 per-slot (minimum dues are $85; maximum dues are
$1,335..) NCCA Membership = $60. (optional) 2008
MSCCA Dues (capacity ________ x $2.40 = $__________
Check Enclosed
____ (Please make checks payable to
MSCCA)
Charge ____
VISA ____ MC _____Discover ____ AMEX
Account Number:________________________ Expires:______________ CVV
Code: _________ (You MUST include the 3-digit CVV code on the back of your card for all VISA
- MC – Discover Charges) Company name
(if it appears on your card): ____________________________________________________________ ____________________________________________________ _____________________________ Mail the Application and Check to: MSCCA 12808-B Ocean Gateway, Queen
Anne, MD 21657 _________________________________________________________________________ MSCCA - Detailed
Center Information - Page 2 Please
note: this page should be completed for
every facility you want to appear on the member website Center
name as you would like it to appear: Facility
Type (before school, after school, child care center, nursery school,
kindergarten): Child
Care Administration License # Accreditation
(NECPA, MSDE, NAEYC, NSACA etc.): Association
Membership other than MSCCA & NCCA (NAEYC, NSACA, etc.): Founding
Year: MSCCA
Member Since: Total
Licensed Capacity: Days
of Operation: Age Range: Hours
of Operation: Toilet
Training Required: Yes No Type
of Care: (Full day care, part day care, evening care, sick child, etc.) Special
services: Transportation
available: Yes No Meals
provided: Snacks
Provided: Yes No Provide
for children with special needs:
Yes No Case by Case Number
of staff members: Average
staff tenure: Head
Teacher’s Degree: First
Aid/CPR Certified (number of staff members): Admission
requirements Parent
interview: Yes No Immunization: Yes No What
is the fee? Per
week? Per month? Activities: Art Y N Library/stories/books Y
N Computers Y
N Music Y
N Cooking Y
N Outdoor
Playground Y
N Drama Y
N Science Y
N Dance Y
N Swimming Y
N Field
Trips Y
N Sports Y
N Other
activities? LIMITATION OF
LIABILITY: The information provided above will be published on the MSCCA
website and available to the general public.
MSCCA, its officers, directors, and agents make no warranties and
accept no liability for damages or loss of business in any manner directly or
indirectly related to the publication of this data, including without
limitation, errors or omissions in the presentation or dissemination of this
data, in any format or by any medium.
Submission of this form constitutes agreement with these terms. 01/01/2007
NCCA
Dues ($60. - optional) __________
TOTAL $__________
Cardholder Name: ________________________________________ Zip
Code of billing address:_______________
Signature Date
Yes No