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IALCCC Membership Application

Annual Dues $150 per Center
Dues include membership to the National Child Care Association (NCCA)

Please complete a separate form for each center.

The IALCCC uses the secure online payment service PayPal.

Payment options include:
VISA - MasterCard - AMEX - Discover - Bank Transfer - PayPal
(A PayPal account is not required to use this service.)

If you prefer to pay by check, please click here for a printable application.

STEP 1: Application

Voting Representative
Voting Representative
to the IALCCC is the:		 Owner
Director
Other
Name:
Mailing Address:
City:
State:
Zip:
E-Mail:
Phone: ()-- (xxx)-xxx-xxxx
FAX: xxx-xxx-xxxx
I am interested in sharing my skills as a member of: Active Member
IALCCC Committee
IALCCC Board of Directors

Center Information
Items marked with * will appear on the IALCCC Members page.
Name of Center:      *
County:
Licensing Region:
Street Address:   *
City:   *
State:   *
Zip:   *
Center Phone: ()--  *
(xxx)-xxx-xxxx
Website Address:  *
Email Address:  *
Hours of Operation:
Directors Name:   *
Year Opened: yyyy
Number of Employees: (full + part time)
This Center is: For-Profit
Non-Profit
This Center Accepts CCDF Vouchers: Does not accept CCDF
Accepts CCDF

The IALCCC uses the secure online payment service PayPal.
Payment options include:

VISA - MasterCard - AMEX - Discover - Bank Transfer - PayPal

(A PayPal account is not required to use this service.)
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