4PXP Membership Enrollment & Update Form — For Provider/Owners of Type III Centers
Welcome! This form is for Provider/Owners of Type III Centers in Louisiana to:Enroll in a new center-based 4PXP Membership, Renew a previous membership that has expired, or update your current membership to align with our new plan🛑 Important: This form must be completed by the Provider/Owner who is enrolling the center in membership. Only Provider/Owners can initiate membership and unlock full access to 4PXP benefits.Membership is registered by center, and includes full benefits for all listed Provider/Owners, as well as certificates and member level rates for the staff you choose to include, based on your selected plan. If you own only one center, please list: All Provider/Owners and Staff you want to include in this membership. If you own multiple centers with other Providers/Owners you do not need to be listed on each individual center’s plan, as long as the provider/owners are appropriately distributed and acknowledged later in this form. Please complete all sections to ensure your: Provider/Owner profile, Center information, Membership enrollment & level, Staff list (for certificate purposes), and Communication info are accurate and up to date.
Type III & Provider(s)/Owner(s) Information
Provider/Owner’s Name (must be the person completing this form.)
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First Name
Last Name
Provider/Owner’s Cell Phone Number (the phone number of the person completing this form, there will be a spot further down to add each provider.)
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Please enter a valid phone number.
Format: (000) 000-0000.
Provider/Owner’s Email Address (the email address of the person completing this form, there will be a spot further down to add each provider.)
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example@example.com
How many years have you worked in ECE?
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How did you learn about 4PXP?
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Please Select
Instagram
Facebook
LinkedIn
Let's Talk Advocacy
Early Childhood Teacher's Corps (ECTC)
Louisiana Early Childhood Educator Apprentice Program (LECEA)
Invite from Another Provider
Email
Text
Other not listed
Please upload a professional headshot for the Provider/Owner completing this form.
Do you give 4PXP permission to use this headshot for member profiles, membership benefits, and other marketing materials?
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Please Select
Yes, I give permission
No, I do not give permission
I am not uploading a professional headshot at this time.
Do you give 4PXP permission to use your photo or video likeness in print and digital materials (e.g. this will be photos and videos from zoom calls, convenings, conference, and other meetings,) for public facing communications?
Yes, I give permission
No, I do not give permission
4PXP Communication
Please provide the contact information where you would like to receive communications from 4PXP. We primarily use email and text messages to send important updates, reminders, recaps, advocacy efforts, breaking news, and program opportunities. This email address and cell phone number for the Provider/Owner's.
I authorize the provider/owner email address I entered above is my best email address and I authorize 4PXP to send communications via email. I understand that I can opt out at any time by utilizing the unsubscribe feature at the bottom of the email blasts or by emailing info@forprovidersbyproviders.org. I also understand if I opt out I will limit myself on communication and resources which are benefits of my membership.*
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Yes, I, authorize 4PXP to send me communication via email.
No, I, do not authorize 4PXP to send me communication via email and understand this will limit my benefits of communication and resources of my membership.
I authorize the provider/owner cell phone number I entered above is my contact number for phone calls and text messages and I authorize 4PXP to send communications via text messaging. I understand that I can opt out at any time by replying STOP of the text message blasts or by emailing info@forprovidersbyproviders.org. I also understand if I opt out I will limit myself on communication and resources which are benefits of my membership.**
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Yes, I, authorize 4PXP to send me communication via text messaging.
No, I, do not authorize 4PXP to send me communication via text messaging and understand this will limit my benefits of communication and resources of my membership.
Do you authorize 4PXP to add you to our 4PXP Provider Community Group Me Platform for Providers/Owners who are members of 4PXP? Group Me is limited to verified providers/owners only who are signed up on 4PXP Membership forms. This is where we share timely reminders, real-time updates, peer connections, events happening, want feedback, drop resources, and advocacy actions. GroupMe is an informal communication tool, it is considered an extension of your professional membership. All members are expected to follow 4PXP's Respectful Engagement at all times. While 4PXP fosters respectful and supportive communication within our GroupMe threads, we cannot vet or moderate every message shared by members. If you wish to opt out later, you may remove yourself from the GroupMe group or email info@forprovidersbyproviders.org.**
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Yes, I, will join the 4PXP GroupMe Thread and will uphold the 4PXP’s Respectful Engagement Policy, and understand violations may result in removal from the GroupMe channel.
No, I, will not join the 4PXP GroupMe Thread and I understand that will limit my benefits of communication and resources of my membership.
4PXP Provider Directory Consent & Details:
Do you want to be listed in the public 4PXP Provider Directory?
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Yes
No
If you have a center website, please list the website address here, you will give consent in the next questions. If you do not have a website please write n/a. If you don’t want your website listed on the provider directory, please put don’t list.
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Please list all of your social media for you or your center please list it here, (Facebook, Instagram, LinkedIn, TikTok, Twitter) and after each one put if you want it listed or not listed. If none, type in n/a.
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Type III Center Details
Type III Center Name
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Type III Center's LDOE License Number
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What Parish is the Type III center located in?
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Type III Center's Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Center's Email Address
*
example@example.com
Center's Contact Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Center's Anniversary Date:
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-
Month
-
Day
Year
Date
What is your center's enrollment capacity?
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Small Center (less than 50 children)
Medium Center (50–99 children)
Large Center (100 or more children)
Center's Current Enrollment Number: (Please enter as a numeric value ex. 45)
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How many Provider/Owners are affiliated with this center including yourself?
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Do you own more than one center with any of these other Provider/Owners?
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Yes
No
Additional Provider/Owners Information
Provider/Owner #2 Full Name
First Name
Last Name
Provider/Owner #2 Email Address
example@example.com
Provider/Owner #2 Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Confirming Provider/Owners #2 membership is being allocated to:
This center’s membership.
Another center’s membership.
Provider/Owner #3 Full Name
First Name
Last Name
Provider/Owner #3 Email Address
example@example.com
Provider/Owner #3 Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Confirming Provider/Owners #3 membership is being allocated to:
This center’s membership.
Another center’s membership.
Provider/Owner #4 Full Name
First Name
Last Name
Provider/Owner #4 Email Address
example@example.com
Provider/Owner #4 Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Confirming Provider/Owners #4 membership is being allocated to:
This center’s membership.
Another center’s membership.
Additional Staff Membership
How many people are on your leadership team for this center?
How many teachers do you have employed?
How many teachers are you currently hiring for?
Is there any other staff you are hiring for? Please answer yes/no and list the position and number of people you are aiming to hire per position.
How many staff members do you have excluding all providers name/owners that you are including in this membership? This staff will receive the benefits of a membership certificate and member discounted conference pricing.
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How many staff members are in need of their CDA?
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Membership & Payment
If you are a current member you can bypass the payment, we will convert your file over with this information and send you an invoice if they fee is above your current payment amount. If you are a new or lapsed member here is the link for the payment of the level that was recommended based on your inputs: https://givebutter.com/4PXPMembership
Attestation: By submitting this form, I affirm that all information provided is true and accurate to the best of my knowledge. I confirm that I am the Provider/Owner of the center listed in this application.
Submit
Submit
Should be Empty: