Siskiyou County Local Child Care Planning Council

Membership Application

 

 

Name: ______________________________________      Phone Number: _______________________

Address: ___________________________________________________________________________

Organization: ________________________________________    Title: _____________________________________
Membership Category:
(Check all that apply)

Parent ____ 
Provider ____ 
Community Rep. ____ 
Agency ____ 
Government ____
Other:_________________

I am interested in serving on the Siskiyou County Local Child Care Planning Council for the following reasons:
 
 
 
 
 
 
 
 
 

Please state your qualifications related to your interest in child care.
 
 
 
 
 
 
 
 
 

DATE:______________________ SIGNATURE:____________________________________

Return to:  Emily Lacroix, Siskiyou County Local Child Care Planning Council, 575 White Avenue, Weed  CA   96094