WSFCCA MEMBERSHIP APPLICATION 2018-2019
NAME ____________________________________________________
BUSINESS NAME ________________________________________________
ADDRESS _________________________________________________
CITY ____________________________ STATE _____ ZIP _________
PHONE _____________________ EMAIL: ______________________
STARS ID _________________________________________________
FULL MEMBER (LICENSED) ____ ASSOCIATE MEMBER (RETIRED) ___
CHOOSE YOUR CHAPTER _____________________________________
DUES FOR THAT CHAPTER $_____________
ACCIDENTAL MEDICAL INSURANCE (THIS IS NOT LIABILITY)
$50.00 per year for up to 12 children. October 1, 2017 - Sept 30, 2018
This accidental/medical insurance is a secondary coverage to the parent's insurance. It will pick up what the parent's insurance does not cover or all costs (up the maximum limit) if there is no insurance.
Contact Wendy Avery immediately should an accident happen and you want to file a claim. 206-898-0999
Chapter Dues $___________
Accidental/Medical $___________
TOTAL DUE $___________
Visit our
website to register online and/or pay by credit card OR
mail check or money order to Jessica Dixon, WSFCCA Membership,
11415 NE 21st St., Bellevue, WA 98004. Make checks payable to Washington State Family Child Care Association.
|