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Name/Nombre
|
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Address/Dirección
Postal
|
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City, Zip/ Ciudad, Código
Postal
|
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Phone/Teléfono
|
Fax
|
|
Email/Correo Electrónico
|
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Facility License Number/Número de
Licencia |
| |
|
Birthday/ -
________________ Month _________ Day of
Month
Cumpleaños
_______________ Mes _________ Día
de los mes
|
|
Member/Miembre -
_____ New/Nueva
______ Renewal/ |
|
License Capacity ____6
____8 ____ 12
____14 |
|
All Languages spoken/Se habla: English/Ingles
____ Spanish/Español____ Other/Otra _________________ |
| |
|
|
Ages of children/edades de niños s
preferencia |
0-1____
1-3 ____ 3-5____
6 and up_____ |
|
Days of operation/días abierto |
|
|
Hours/horas |
|
|
Closest School/escuela mas cercano |
|
| |
|
| |
|
|
I give permission to the Department of
Social Services to inform the Monterey County Family Child Care Association
in the case of a formal investigation involving me as a licensed family
child care provider. It is my understanding that MCFCCA will
temporarily suspend my membership and referrals until the charges against me
have been resolved.
Doy mi autorización al
Departamento de Servicios Sociales de informar a la MCFCCA en caso de una
investigación formal acerca de mi persona como un proveedor de cudado
infantile con licencia. Entiendo que la MCFCCA suspenderá mi membresia
temporalmente y no darán referencias mias hasta que los cargos en mi contra
sean esclarecidos.
______________________________________________
__________________________
Signature/Firma
Date/Fecha |
| |
|
Membership/Membresia |
Joining Fee*/ |
Dues/Vencimiento |
Total |
|
Regular (licensed provider) |
$10 |
$50 |
$60 |
|
Associate |
$10 |
$20 |
$30 |
|
|
|
*This is a one time fee
Send this application, a check for your
dues, a copy of your License, and a copy of your cancelled check to DSS for
your annual licensing fee to:
MCFCCA
P.O.Box 4122
Salinas, CA 93912 |
| |
