4PXP Membership Enrollment & Current Membership Update Form — For Provider/Owners of Type III Centers

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Image Field
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Membership Status:* This field is required.
I am signing up for a new 4PXP membership (I have never been a member before.)
I am a previous 4PXP member and want to rejoin membership
I am a current member of 4PXP and need to convert my membership over to the new plan
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Provider/Owner’s Name (must be the person completing this form.)* This field is required.
First Name
Last Name
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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.)* This field is required.
Please enter a valid phone number.
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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.)* This field is required.
example@example.com
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Provider/Owner's Last 4 digits of SSN (the person completing this form.)* This field is required.
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How many years have you worked in ECE?
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How did you learn about For Providers By Providers (4PXP)? * This field is required.
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What are the reasons that you are becoming a member of For Providers By Providers (4PXP)* This field is required.
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Please upload a professional headshot for the Provider/Owner completing this form.
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Image FieldPlease upload a professional headshot for the Provider/Owner, completing this form.
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Do you give 4PXP permission to use this headshot for member profiles, membership benefits, and other marketing materials?* This field is required.
Please Select
Please Select
Yes, I give permission
No, I do not give permission
I am not uploading a professional headshot at this time.
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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
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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.** This field is required.
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.
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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.*** This field is required.
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.
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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.*** This field is required.
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.
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How would you like your name to be displayed in Group Me?** This field is required.
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Do you want to be listed in the public 4PXP Provider Directory?* This field is required.
Yes
No
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Do you have a website for your Center?* This field is required.
Yes
No
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If you have a center website, please list the website address here, you will give consent in the next questions. * This field is required.
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Do you give us consent to post your website in your profile of the 4PXP Provider Directory?* This field is required.
Yes
No
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Do you have a facebook page for your center?* This field is required.
Yes
No
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If you have a center facebook page, please list the address for the facebook page here, you will give consent in the next questions. * This field is required.
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Do you give us consent to post your Facebook page on your profile of the 4PXP Provider Directory?* This field is required.
Yes
No
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Do you have an Instagram page for your center?* This field is required.
Yes
No
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If you have a center Instagram page, please list the Instagram handle here, you will give consent in the next questions. * This field is required.
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Do you give us consent to post your Instagram handle on your profile of the 4PXP Provider Directory?* This field is required.
Yes
No
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If you have other social media for you or your center please list it here, and after each one put if you want it listed or not listed. If none, type in n/a.* This field is required.
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Type III Center Name* This field is required.
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Type III Center's LDOE License Number* This field is required.
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What Parish is the Type III center located in?* This field is required.
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Type III Center's Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Center's Email Address* This field is required.
example@example.com
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Center's Contact Number* This field is required.
Please enter a valid phone number.
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Center's Anniversary Date:* This field is required.
Date
Month
Day
Year
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What is your center's enrollment capacity?* This field is required.
Small Center (less than 50 children)
Medium Center (50–99 children)
Large Center (100 or more children)
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Center's Current Enrollment Number: (Please enter as a numeric value ex. 45)* This field is required.
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Are there any other provider(s)/owner(s) for this center?* This field is required.
Yes
No
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How many Provider/Owners are affiliated with this center including yourself? * This field is required.
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Do you own more than one center with any of these other Provider/Owners?* This field is required.
Yes
No
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Provider/Owner #2 Full Name* This field is required.
First Name
Last Name
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Provider/Owner #2 Email Address* This field is required.
example@example.com
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Provider/Owner #2 Phone Number* This field is required.
Please enter a valid phone number.
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Confirming Provider/Owners #2 membership is being allocated to:* This field is required.
This center’s membership.
Another center’s membership.
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Provider/Owner #3 Full Name* This field is required.
First Name
Last Name
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Provider/Owner #3 Email Address* This field is required.
example@example.com
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Provider/Owner #3 Phone Number* This field is required.
Please enter a valid phone number.
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Confirming Provider/Owners #3 membership is being allocated to:* This field is required.
This center’s membership.
Another center’s membership.
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Provider/Owner #4 Full Name* This field is required.
First Name
Last Name
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Provider/Owner #4 Email Address* This field is required.
example@example.com
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Provider/Owner #4 Phone Number* This field is required.
Please enter a valid phone number.
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Confirming Provider/Owners #4 membership is being allocated to:* This field is required.
This center’s membership.
Another center’s membership.
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How many people are on your leadership team for this center?
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How many teachers do you have employed?
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How many teachers are you currently hiring for?
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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.
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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. * This field is required.
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How many staff members are in need of their CDA?* This field is required.
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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.
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