4PXP Membership Enrollment & Current Member Update Form for FCC Homes

1
Image Field
2
4PXP Membership Enrollment & Current Members Update Form - For Provider/Owners of FCC Homes

This form is for Provider/Owners of Family Child Care (FCC) in Louisiana enrolling/updating their 4PXP Membership.

Yes, if you are a previous 4PXP member that has expired, updating an existing membership to align with our new plan, or getting membership for the first time complete this form. All FCC Memberships cover up to two individuals—many FCCs 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:

✅ FCC Provider/Owner Profile details

✅ Communication

✅ Provider Directory

✅ FCC Details

✅ Additional Member Information

If you need assistance at any point please reach out via phone/text 504-229-9799 or via email to info@forprovidersbyproviders.org
3
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 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
4
FCC Provider/Owner's Name * This field is required.This must be the person completing this form. Only a provider/owner may complete this form on behalf of an FCC Home.
First Name
Last Name
5
FCC Provider/Owner's Email Address* This field is required.This must be the email address of the person completing this form. This will be used for all membership-related communications.
example@example.com
6
FCC Provider/Owner's Cell Phone Number* This field is required.This must be the cell phone of the person completing this form. This number will be used for GroupMe and other important text alerts, if you sign off to be communicated by this method. Please ensure the number you enter here accepts text messages.
Please enter a valid phone number.
7
FCC Provider/Owner's last 4 digits of SSN* This field is required.This must be the last four of the Social Security Number of the person completing this form. This will be included on the membership certificate for verification for all state programs that require membership.
8
How many years have you worked in Early Childhood Education?* This field is required.Please enter the number only (not words).
9
How did you learn about For Providers By Providers (4PXP)?* This field is required.
10
What are the reasons that you are becoming a member of For Providers By Providers (4PXP)?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
11
Please upload a professional headshot of the Provider/Owner that is completing this form. 🔹 Accepted file types: JPG, PNG, or PDF
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
12
Do you give For Providers By Providers (4PXP) permission to use this headshot for member profiles, membership benefits, programs, and other membership-related purposes, as well as for marketing materials?* This field is required.Please respond here even if you submit your professional headshot in an additional document, upload in the portal, or send to us through email/text formatting. .
YESNO
13
Do you give For Providers By Providers (4PXP) permission to take and use your photo, video, and/or audio recordings for storytelling, member profiles, promotional materials, and other membership-related purposes, including digital and print marketing?* This field is required.
YES, I give permission. NO, I do not give permission. I understand that this may impact my ability to not only be featured in membership programs or materials that include photos or recordings from in-person events but also to attend.
14
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 communications via email blasts.
No, I, do not authorize 4PXP to send me communications via email blasts and understand this will limit my benefits of communication and resources of my membership.
15
The provider/owner cell phone number I entered above is my best contact number. I authorize 4PXP to send communications to this phone number via SMS/text messaging. I understand that I can opt out at any time by replying STOP or by contacting info@forprovidersbyproviders.org* This field is required.
Yes, I, authorize 4PXP to send me communications via text messaging blasts.
No, I, do not authorize 4PXP to send me communications via text messaging blasts and understand this will limit my benefits of communication and resources of my membership.
16
I confirm that I am a Provider/Owner of an FCC and authorize 4PXP to add me to the 4PXP Provider/Owner Community GroupMe platform "4PXP Talkback: Provider Power Line", which is exclusively for 4PXP member providers and owners . GroupMe is used to share timely reminders, real-time updates, peer connections, resources, events, and advocacy actions. This platform is considered an extension of your professional membership and is an informal tool, only verified providers/owners with an active 4PXP membership will be added, and all members are expected to follow 4PXP's Respectful Engagement guidelines. I understand that while 4PXP fosters respectful and supportive communication, we cannot vet every message shared by members. Based on my personal GroupMe settings, I may receive notifications by email or text message in addition to the platform. I can change these notifications at any time. In addition, depending on my settings, my phone number may be visible to other members of the GroupMe group. I may opt out at any time by leaving the GroupMe group or by contacting info@forprovidersbyproviders.org.* This field is required.
Yes, I authorize 4PXP to add me to the GroupMe thread, I understand the policies and the plan as written above.
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.
17
How would you like your name to be displayed in Group Me?* This field is required.This helps other members recognize you in the thread.
18
Do you want your FCC to be listed in the public 4PXP Provider Directory?* This field is required.
Yes, I would like my FCC listed in the public directory.
No, I would not like my FCC listed in the public directory and am waiving this benefit.
19
If you chose, yes, to being listed in the public 4PXP Provider Directory, how do you want your FCC name displayed?* This field is required.
20
If you chose, yes to being listed in the public 4PXP Provider Directory, Enter the best public-facing email for your center.* This field is required.
example@example.com
21
Do you have a website for your FCC? If you have a website, Do you give 4PXP consent to publish your FCC's website in your profile of the 4PXP Provider Directory and other membership benefits section including marketing materials* This field is required.
Yes I have a website and I give 4PXP consent to publish my website in the Provider Directory and other marketing materials.
Yes, I have a website and I DO NOT give 4PXP consent to publish my website in the Provider Director and other marketing materials. I understand I am waiving that benefit of my membership.
No, I do not have a website at this time. I understand I am waiving that benefit of my membership.
22
If you have a website for your FCC, please share the link to the website address here. If you do not have a website please type n/a.* This field is required.We will only publish the website if you have given us permission in the above question otherwise it will be for internal reference purposes and support. Ex. www.forprovidersbyproviders.org
23
Do you have a Facebook Page for your FCC? If you have a Facebook Page, Do you give 4PXP consent to publish the link to your FCC's Facebook Page in your profile of the 4PXP Provider Directory and other membership benefits section including marketing materials* This field is required.
Yes I have a FCC Facebook Page and I give 4PXP consent to publish the link in the Provider Directory and other marketing materials.
Yes, I have a FCC Facebook Page and I DO NOT give 4PXP consent to publish the link in the Provider Director and other marketing materials. I understand I am waiving that benefit of my membership.
No, I do not have a website at this time. I understand I am waiving that benefit of my membership.
24
If you have a Facebook page for your FCC, please list the link here. If you do not have a Facebook page please type n/a.* This field is required.We will only publish the Facebook page if you have given us permission in the above question otherwise it will be for internal reference purposes and support. Ex. https://www.facebook.com/4PXPLA
25
Do you have an Instagram Handle for your FCC? If you have a Instagram Handle, Do you give 4PXP consent to publish the link to your FCC's Instagram's Handle in your profile of the 4PXP Provider Directory and other membership benefits section including marketing materials* This field is required.
Yes I have a FCC Instagram Handle and I give 4PXP consent to publish the handle in the Provider Directory and other marketing materials.
Yes, I have a FCC Instagram Handle and I DO NOT give 4PXP consent to publish the handle in the Provider Director and other marketing materials. I understand I am waiving that benefit of my membership.
No, I do not have a Instagram Handle at this time. I understand I am waiving that benefit of my membership.
26
If you have an Instagram handle or link to your FCC Instagram page, please list the link here. If you do not have a Instagram handle please type n/a.* This field is required.We will only publish the Instagram handle if you have given us permission in the above question otherwise it will be for internal reference purposes and support.Ex. https://www.instagram.com/forprovidersxproviders/
27
Do you have a Linked In Page for yourself and/or your FCC? If you have a Linked In Page, Do you give 4PXP consent to publish the link to your Linked In Pages in your profile of the 4PXP Provider Directory and other membership benefits section including marketing materials* This field is required.
Yes I have a LinkedIn Page for myself and/or my FCC and I give 4PXP consent to publish the pages in the Provider Directory and other marketing materials.
Yes, I have a LinkedIn Page for myself and I give 4PXP consent to publish the Linked In Page for myself in the Provider Director and other marketing materials. I am not giving permission to publish my FCC LinkedIn Page.
Yes, I have a LinkedIn Page for my FCC and I give 4PXP consent to publish the Linked In Page for my FCC in the Provider Director and other marketing materials. I am not giving permission to publish my LinkedIn Page for myself.
No, I do not have a LinkedIn Page for myself or my FCC at this time. I understand I am waiving that benefit of my membership.
28
If you have a LinkedIn Pages for yourself and/or your FCC, please list the link here. If you do not have a LinkedIn page please type n/a.* This field is required.We will only publish the LinkedIn Pages that you have given us permission in the above question otherwise it will be for internal reference purposes and support. Ex. https://www.linkedin.com/in/4pxp/
29
If you have other social media pages or links for your FCC please list them below. For each link, indicate whether or not you want it included in your 4PXP Provider Directory profile. If you do not have any additional page/links to list type n/a:* This field is required.Ex. TikTok: @myfccpage - Yes, list or Twitter: @myfccpage - No, don't list
30
FCC Name as listed with LDOE* This field is required.
31
FCC LDOE License Number* This field is required.
32
What Parish is your FCC located in?* This field is required.
33
FCC's Address (Your home'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
34
FCC Anniversary Date
Date
Year
Month
Day
35
FCC’s Current Enrollment
Please Select
Please Select
None
1
2
3
4
5
6
36
Please upload a copy of your FCC logo. Uploading the logo is giving us consent to use it on provider directory and other marketing materials. If you don’t want to consent, please don’t upload it.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
37
Is there a second Provider/Owner, a Teacher, or support person?* This field is required.
Yes
No
38
Full Name of Secondary Person being listed on Membership:* This field is required.
39
Role of Secondary Person being listed on Membership:* This field is required.
Please Select
Please Select
Provider/Owner
Teacher/Assistant
Support Person
40
Secondary Person being listed on the Membership email address:* This field is required.
example@example.com
41
Secondary Person being listed on the Membership cell phone number:* This field is required.
Please enter a valid phone number.
42
Secondary Person being listed on Membership last 4 digits of SSN* This field is required.This must be the last four of the Social Security Number of the person completing this form. This will be included on the membership certificate for verification for all state programs that require membership.
43
Secondary person's hire date:
Date
Year
Month
Day
44
How many years have you worked in Early Childhood Education?* This field is required.Please enter the number only (not words).
45
Please upload a professional headshot of the Secondary Person if they are a Provider/Owner. 🔹 Accepted file types: JPG, PNG, or PDF
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
46
Do you give For Providers By Providers (4PXP) permission to use this headshot for member profiles, membership benefits, programs, and other membership-related purposes, as well as for marketing materials?* This field is required.Please respond here even if you submit your professional headshot in an additional document, upload in the portal, or send to us through email/text formatting. .
YESNO
47
Do you give For Providers By Providers (4PXP) permission to take and use your photo, video, and/or audio recordings for storytelling, member profiles, promotional materials, and other membership-related purposes, including digital and print marketing?* This field is required.
YES, I give permission. NO, I do not give permission. I understand that this may impact my ability to not only be featured in membership programs or materials that include photos or recordings from in-person events but also to attend.
48
The provider/owner email address (2nd provider/owner) 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 communications via email blasts.
No, I, do not authorize 4PXP to send me communications via email blasts and understand this will limit my benefits of communication and resources of my membership.
49
The provider/owner cell phone number (2nd provider/owner) entered above is my best contact number. I authorize 4PXP to send communications to this phone number via SMS/text messaging. I understand that I can opt out at any time by replying STOP or by contacting info@forprovidersbyproviders.org* This field is required.
Yes, I, authorize 4PXP to send me communications via text messaging blasts.
No, I, do not authorize 4PXP to send me communications via text messaging blasts and understand this will limit my benefits of communication and resources of my membership.
50
I confirm that I am the 2nd Provider/Owner completing this membership form. I authorize 4PXP to add me to the official 4PXP Provider Community GroupMe platform "4PXP Talkback: Provider Power Line", which is exclusively for 4PXP member providers and owners. GroupMe is used to share timely reminders, real-time updates, peer connections, resources, events, and advocacy actions. This platform is considered an extension of your professional membership and is an informal tool, only verified providers/owners with an active 4PXP membership will be added, and all members are expected to follow 4PXP's Respectful Engagement guidelines. I understand that while 4PXP fosters respectful and supportive communication, we cannot vet every message shared by members. Based on my personal GroupMe settings, I may receive notifications by email or text message in addition to the platform. I can change these notifications at any time. In addition, depending on my settings, my phone number may be visible to other members of the Groupme Group. I may opt to at any time by leaving the GroupMe group or by contacting info@forprovidersbyproviders.org* This field is required.
Yes, I authorize 4PXP to add me to the GroupMe thread, I understand the policies and the plan as written above.
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.
51
How would you like your name to be displayed in Group Me?* This field is required.This helps other members recognize you in the thread.
52
Image Field
53
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 listed in this application and with the Louisiana Department of Education.
Powered by Jotform SignClear
Should be Empty: