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Membership Form
Name
First Name
*
Last Name
*
Type Of Membership
*
Individual
Organization
Email:
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Telephone:
Business/Organization Name, if applicable:
Your Job Title:
Mailing Address
Street
*
City
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State
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Zip
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Work Group, if applicable
Membership
Advocacy/PR
Access to High Quality Services
Data
Agency Description — Please tell us what types of services you provide. (Check all that apply.)
In-home services
Family & Group Family Child Care
Center Based Child Care
Child Care Resource & Referral
Head Start
Early Head Start
Pre-Kindergarten Program
Early Intervention
Preschool Special Education
Library
Parent Support/Education/Family Resource Center
Other
If other, please specify:
Population(s) Served:
Geographic Region Served (if organization) or County of Residence (if individual)
*
Clinton County
Essex County
Franklin County
Saint Regis Mohawk Reservation
Other
If other, please specify:
Funding Sources (Check all that apply):
Local Government
State
Federal
Fee for Service
Philanthropy
Membership Form
