Date

Last Name

First Name       Phone

Address

City/Zip

County     E-Mail

Birthday

Are you: 

                Licensed childcare provider                Class I                       Class II     

Member of a childcare association or group    Name group:  

                Childcare Advocate                               Parent                                      

Agency        Name Agency:  

Would you be interested in serving on any of the following committees?

              By-laws     / Articles                                                Board of Directors

               Membership Coordination                                  Advisory Board

                Publicity Coordination                                         Steering Committee

                Grant writing                                                          Officer

              Conference planning                                             Newsletter

                Meeting Coordinator                                            Rules & Regulation Committee

                Educational / training Coordinator             Publications

               Fund Raising                                                          Calling Coordinator

Other- name 

~Please submit Application,  and send  Dues to:  I C A: P.O. Box 95 Wyatt, IN  46595

 ~  IMPORTANT... You must send a copy of your License in order to receive your membership packet!!!

When we receive your dues,  you will be shipped a membership packet with your Membership number and receipt!

Individual Membership: $55.00/yr

Starting 2006:  all NEW members will be charged a one-time initiation fee for membership.

This fee will be wavered for all existing 2005 members. 

You will Receive a call within 48 hours

                                     Special Notes

Please contact me as soon as possible regarding this matter.