Self-Study Enrollment Form

Self-Study Enrollment Form

Please select the Licensed Capacity of your program during the payment portion to ensure you are paying the correct amount for your submission.
Program Contact Information
Name of Program*
Program Name (as appears on Operating License), include program number if applicable
Name of Onsite Director*

First NameLast Name
Program's Physical Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
County that the Program is Physically Located in*
County
YesNo
Program Mailing Address (if different from above)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Program Phone Number*
Format: (000) 000-0000.
Program Website
Web Address for Program
Program Email Address*
example@example.com
Alternate Email Address
example@example.com
Program Operating Information
Licensed Capacity*
Number of children you are licensed for (not the number enrolled).
Number of Classrooms*
Number of Employees*
YesNo
JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember
MondayTuesdayWednesdayThursdayFridaySaturdaySunday
Hours of Operation*
Times program is open
InfantsToddlersTwosPreschoolSchool Agers
Program Type*
Name of Corporate Affiliation*
If you are a member of a local director's group, please list:
YesNo
Please list through whom you are receiving Accreditation Assistance*
YesNoNo, but I would like to know more
How did you hear about the National Accreditation Commission?*
If other, please list how you heard about the National Accreditation Commission:
Legally Responsible Party

If the legally responsible party is different from above, please complete the items below.
Name of Legally Responsible Party, if different from above

First NameLast Name
Title
Organization/Corporation
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
File Uploads
Upload copy of Program License or Letter of Licensing Exemption*

Only 1 PDF file will be accepted
Cancelof
Agreement
I understand that in order to participate in the accreditation process of the National Accreditation Commission for Early Care and Education Programs, the philosophies of the Program and the Commission must be compatible. The Program will have two years from the date the National Accreditation Commission receives the program’s complete Self-Study application (form, fee, and licensing documentation) to complete the Self-Study phase and request an onsite validation visit. I also understand that the enrollment fee is non-refundable and a validation fee is due when requesting a validation visit.
Full Name of Representative

First NameLast Name
Title of Representative
Signature of Representative*

Clear
Date*

MonthDayYear
Date
Payment Information

My Products

Self-Study Enrollment Fee: please select your programs Licensed Capacity to ensure the correct fee is applied.

Select the appropriate licensed capacity range below to reflect accurate pricing.

$700.00 License Capacity

Hard Copy Accreditation Manual

Optional hard copy in binder format, will be mailed via USPS Media Mail to mailing address above. Please allow 5-10 business days for shipment and 3-5 business days for delivery.

$75.00 Quantity

Subtotal

$0.00

Tax

$0.00

Total

$0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Please verify that you are human
Should be Empty:

Self-Study Enrollment Form

Program Contact Information

Program Operating Information

Legally Responsible Party

File Uploads

Agreement

Payment Information