The National Day Without Child Care ECE Provider Interest & Sign Up Form
Provider's Name
*
First Name
Last Name
Provider's Email
*
example@example.com
Provider's Cell Phone Number
*
-
Area Code
Phone Number
Will you close your center(s) on May 12, 2025 and Join us at the Louisiana State Capitol?
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Yes I will close my center(s) on May 12, 2025, Join on the steps of the Louisiana State Capitol for 8:30 am with my directors, staff, and families.
Maybe, I need more information before deciding to close my center(s) on May 12, 2025
No, I can not close my center(s) on May 12, 2025
How many centers do you own?
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How many centers will you close on Monday, May 12, 2025 in support of Day Without Child Care?
*
Are you committed to talking to other providers and getting at least 5 other providers to close their center(s) on Monday, May 12, 2025? We have a goal to reach of 200 Centers for Louisiana's First Day Without Child Care
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Yes I will commit to getting five providers to close on Monday, May 12, 2025
Maybe, I need more information to support this effort
No, I can not close my center(s) on May 12, 2025
How did you hear about a Day Without Childcare? Did a ECE provider reach out to you if so Provider's name or center's name?
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Center #1 Name
*
Parish Center #1 is located in
*
Type of Center #1 is registered as
*
Please Select
Type III
FCC
Type II
Type I
How many children does center #1 currently serve?
*
I give permission to list Center #1 on marketing material regarding Day Without Child Care
*
Please Select
Yes
No
Center #2 Name
Parish Center #2 is located in
Type of Center #2 is registered as
Please Select
Type III
FCC
Type II
Type I
I give permission to list Center #2 on marketing material regarding Day Without Child Care
Please Select
Yes
No
How many employees does center #2 staff?
How many children does center #2 currently serve?
Center #3 Name
Parish Center #3 is located in
Type of Center #3 is registered as
Please Select
Type III
FCC
Type II
Type I
I give permission to list Center #3 on marketing material regarding Day Without Child Care
Please Select
Yes
No
How many employees does center #3 staff?
How many children does center #3 currently serve?
Center #4 Name
Parish Center #4 is located in
Type of Center #4 is registered as
Please Select
Type III
FCC
Type II
Type I
I give permission to list Center #4 on marketing material regarding Day Without Child Care
Please Select
Yes
No
How many employees does center #4 staff?
How many children does center #4 currently serve?
Center #5 Name
Parish Center #5 is located in
Type of Center #5 is registered as
Please Select
Type III
FCC
Type II
Type I
I give permission to list Center #5 on marketing material regarding Day Without Child Care
Please Select
Yes
No
How many employees does center #5 staff?
How many children does center #5 currently serve?
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All together, Approximately how many parents and families do you have contact info on that you can invite?
*
Please list any thoughts, ideas, and concerns here for us:
Submit
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