Membership Form
Complete and mail to:

CCFDCA Annual Membership
C/O Melissa Robey
751 Texola Ct
Lusby, MD 20657


ANNUAL DUES:  $25.00
All memberships run from June 1st through May 31st of the next year.

PLEASE MAKE CHECKS PAYABLE TO
CCFDCA

NAME:  ____________________________________________________________

CHECK NUMBER:_____________

OFFICE OF CHILD CARE LICENSE/REGISTRATION
NUMBER:_________________________

NEW MEMBER:  _________  OR RENEWAL:________________

CURRENT MEMBERSHIP NUMBER:  _____________________

ADDRESS:_________________________________________________________

__________________________________________________________________


STATE:  ____________        ZIP CODE:  _________________

PHONE:  __________________________________________

E-MAIL:  
_________________________________________________________________
     We open membership to childcare providers that hold
current MSDE Office of Child Care Licensing and
Regulation Certificates.  Verification will take place prior
to activating membership and it's benefits.