Healthy Childcare Champions Interest Form
Please complete the following questions. I will follow up with you to request 45 minutes to meet with you (in-person or virtually) to complete the Eco-Healthy Childcare® endorsement. Upon completion of the endorsement, I will deliver free supplies to your facility to help you get started on eco-healthy best practices.
Name of Facility Owner/Director
First Name
Last Name
Facility Name
Facility Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Email
example@example.com
Facility Phone
Please enter a valid phone number.
Provider Cell Phone
Please enter a valid phone number.
# of children cared for by facility on a daily basis
Licensed capacity (# of children that you are licensed to care for)
License Number
Type of Childcare Facility
Please Select
Family Childcare
Center-Based
Have you ever been endorsed by the Eco-Healthy Child Care® program?
Please Select
Yes
No
Pennsylvania Professional Development (PA KEY) Registry ID Number:
To find your Registry ID, go to https://www.papdregistry.org/ and log in to your account. Your Registry ID is located on your personal profile page.
How would you like to be reached for follow-up?
Call to facility phone
Call to cell phone
Email
Text
Submit
Should be Empty: