MARYLAND STATE CHILD CARE ASSOCIATION
2010 Membership Application & Center Profile
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: _______
TOTAL NUMBER OF EMPLOYEES AT THIS CENTER: ______
DATE OF APPLICATION: _________________
LICENSED CAPACITY OF THIS CENTER: _________________
FOR PROFIT: _____ NON-PROFIT: ______
ACCEPT CHILD CARE SUBSIDY VOUCHERS (Yes/No): _____
CENTER LISTING CONTACT NAME:____________________________________________________________________
TITLE: ________________________________________________________________________
NAME OF CENTER:_________________________________________________________________________
STREET:___________________________________________________________________________________
P. O. BOX (if applicable)______________________________________________________________________
CITY:______________________________________________________________________________________
STATE: ____________ ZIP CODE: _______________ COUNTY: ______________________
WORK PHONE: ______________________________
FAX:_______________________________________
EMAIL:___________________________________________________________________________________
(Listing your center OR at-home Email contact will assure receipt of important notices on an ongoing basis)
OWNER’S NAME & ADDRESS (if different from above):Preferred Customer:
______________________________________________________________________________________
______________________________________________________________________________________
2010 MSCCA Dues (capacity ________ x $2.70 = $__________
(Minimum dues are $100 ie. if your Center is licensed for less than 38 children)
National Child Care Association Annual Dues ($60.Optional)
TOTAL$__________
Note: There will be a 5% Service Charge added to all Credit Card Membership Payments
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)
Print Cardholder Name:_____________________________________________________________________
Zip Code of billing address______________
Print Company name (if it appears on your card):_____________________________________________________________________________________
_____________________________ ____________________________________
Signature Date
Mail the Application and Check to:
MSCCA
12808-B Ocean Gateway, Queen Anne, MD 21657