Please print out this form to mail
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Child Care Providers Coalition Of Kansas,Inc.
** NOTE If this is a renewal, your expiration date shows on your newsletter label. Please renew before the date shown to assure continued receipt of your membership services.
Membership Year
One year from the date you join.
Name:_____________________________________________________
Business Name:_____________________________________________
Address:___________________________________________________
City:_______________________________CO___________________State:_____Zip:_______
Phone Number:________________________________
E-Mail:_____________________________________________________
PLEASE CHECK ALL THAT APPLY
NEW_____ RENEWAL______
_____ CCPC Membership - $20.00
_____ CCPC MEM & NAFCC MEM -$50.00
Registered FCC___ Lic FCC___ Group FCC___
_____Supportive Membership $20.00
CC Center_____ R&R_____
What association benefits interest you:
Professional Development_____ Advocacy_____ Newsletter_____ Discounts_____ Other_____
Are you a member of a local association?
Yes, Name_________________________________
No_____
Would you like to help CCPC?_____
Please make check or MO payable to CCPC
Returned check fee: $10.00
Please allow 4 weeks for processing
Send to CCPC, P.O. Box 121,
Emporia, KS 66801
**************Office Use Only***************
Date Received______________Amount$_________
Check #_________________ Card Sent______(KDHE)
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