First Name *
Last Name *
Date of Birth * Please type in as follows, including the dashes: YYYY-MM-DD Por favor, escrÃbalo de la siguiente manera, incluyendo los guiones: AAAA-MM-DD
Address *
Address 2
City *
State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip *
Phone *
Is the above phone number a cell phone? * Yes / I prefer to receive text messages Yes / I prefer not to receive text messages No / This is not a cell number
Email *
When is the best time to reach you? * Morning Afternoon Evening
Language Preference * English Spanish
Additional languages you speak fluently (If Applicable)
Cultural or Racial Group * Black/African AmericanWhiteAsianNative American/American Indian/Alaskan IndianNative Hawaiian/Pacific IslanderHispanic/LatinoMulti-racialI choose not to discloseOther
Education: Please select those that apply to you. * CDA (Child Development Associate)Some College CreditsAssociate DegreeBachelor DegreeMaster's DegreeNone of the Above
Please list the title of your major(s) that correspond with the question above. (If Applicable)
Please choose the option that best describes your current situation: * I provide child care in my own home. I provide child care at a residence other than my own home. I provide child care at a center. I do not currently provide child care.
How old are the children you serve? (If applicable, select all that apply) InfantToddlerPreschoolerSchool-Age
Hours of Operation
Days of Operation (Please select all that apply) SundayMondayTuesdayWednesdayThursdayFridaySaturday
Business Structure * Sole Proprietor/Individual Partnership LLC S Corporation Don't Know
Do you have a Nebraska child care license? * Yes No
Please Choose the Child Care License you hold * FCCI FCCII Preschool-Only Center
Are you currently operating as License Exempt? * YesNoDon't Know
License Number (If Applicable)
Do you accept Child Care Subsidy (aka Title XX)? * Yes, children in care Yes, no current children in care No Don't Know
Do you participate in Step Up to Quality? * Yes No Don't Know
What step are you? *
Do you participate in the Child and Adult Care Food Program (CACFP)? * Yes No Don't Know
Do you currently work in a job outside of providing child care? * Yes, Full Time Yes, Part Time No
How did you hear about us? * Advertisement Colleague, Friend, Co-worker Conference Mailing or Newsletter Other State/Local Organization or Agency Social Media (Facebook, Pinterest, Instagram, etc) Training or Professional Development in my State Web or online search Word of Mouth
Which additional NECC Family Child Care Network program(s) are you interested in? Licensing Toolkit (Unlicensed Programs Only)Professional Development TrainingChild Development Associate (CDA) TrainingOther (Please specify below)
Other (Please Specify)
The Nebraska Exchange. I have registered with the Nebraska Early Childhood Exchange at nebraskaexchange.org
Photo Release * NECC may use my photograph, likeness, artwork, profile and/or story in all media forms and any promotional materials. I understand I will not be compensated for this use. I waive any right to approve the final product, including any written copy.
General Consent / Release of Information * NECC may release my membership status including contact information to partner agencies, with which it has a signed agreement, for the purpose of providing other resources I may qualify for. Release will remain in effect until I revoke consent in writing.
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