ACPN Membership Form

Membership Application

Family Child Care, Group Homes, & Centers
Note: If you are adding staff, complete the staff profile page below. NO REFUNDS! ALL PAYMENTS ARE FINAL.
Name

First NameLast Name
Gateways Number
Childcare Program Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
What is your Age Range?
Current Educational Level
Are you working toward a credential advancement or an Early Childhood Education Degree? If so, please check which one(s)
Would you like to receive text message reminders for meetings & events?

Family Childcare

Membership includes 1 additional staff person or assistant.

$150.00

Group Home

Membership includes 2 additional staff or assistants.

$200.00

Childcare Center

Membership includes 3 additional staff or assistants

$300.00

Total

Cohort Requirements:
- 480 hours (6 months) of working in a childcare setting
- High School diploma/GED or currently enrolled/attending high school
Staff Person 1
Staff #1: What Cohorts are your staff interested in?:
Staff Person 2
Staff #2: What Cohorts are your staff interested in:
Staff Person 3
Staff #3: What Cohorts are your staff interested in:
Statement of Agreement: I agree to fulfill all requirements set forth in the bylaws of ACPN. I promise to take my membership seriously and to commit to act responsibly to my ACPN obligations.
Should be Empty:

Membership Application