4PXP Membership Enrollment & Current Member Update Form — For Provider/Owners of FCC Homes
This form is for Provider/Owners of Family Child Care (FCC) Homes in Louisiana to:Enroll in a new FCC-based MembershipRenew a previous membership that has expiredOr update an existing membership to align with our new plan.Membership is registered by center/FCC Home, and includes benefits for you and your staff.All FCC Memberships cover up to two individuals—most FCC homes have only one Provider/Owner, but two are included in case you operate with a co-owner or assistant.Please complete all sections of this form to ensure your:✅ Profile details✅ FCC Home information✅ Membership enrollment✅ Staff list (for certificate purposes)…are accurate and up to date.
Membership Status:
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I am signing up for a new 4PXP membership (I have never been a member before.)
I am a current member of 4PXP and need to convert my membership over to the new plan.
I am a previous 4PXP member and want to rejoin membership
FCC & Provider Information
Provider/Owner's Name (must be the person completing this form)
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First Name
Last Name
FCC Home/Provider's Cell Phone Number
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Please enter a valid phone number.
FCC Home/Provider's Email Address
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example@example.com
Is there a second Provider/Owner, Teacher, or support person?
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Yes
No
Full Name of Secondary Person being listed on Membership:
*
Role of Secondary Person being listed on Membership:
*
Secondary Person being listed on the Membership email address:
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example@example.com
Secondary Person being listed on the Membership cell phone number:
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Please enter a valid phone number.
FCC Home Details
FCC Home Name as listed with LDOE
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FCC Home's LDOE License Number
*
FCC's Home Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What Parish is the FCC home located in?
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4PXP Provider Directory
Do you want to be listed in the public 4PXP Provider Directory?
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Yes
No
Do you have a website for your FCC Home?
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Please Select
Yes
No
Please put in your website address if you want it listed:
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Do you have a Facebook Page for your FCC Home?
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Please Select
Yes
No
Please put in your Facebook Page if you want it listed:
*
Do you have a Instagram Handle for your FCC Home?
*
Please Select
Yes
No
Please put in your Instagram Handle if you want it listed:
*
If you have other social media or links you want listed please list the platform and link here, if you do not have any list n/a:
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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 communications via email.
No, I, do not authorize 4PXP to send me communications 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 communications via text messaging.
No, I, do not authorize 4PXP to send me communications 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, 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 Group Me Thread and I understand that will limit my benefits of communication and resources of my membership.
How would you like your name to be displayed in Group Me?
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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. If you are a new or lapsed member here is the link for the payment of $129: https://givebutter.com/4PXPMembrship
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 FCC Home listed in this application.
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