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Application for Child Care Facility Accreditation

Please note: you can type directly into this form and then print it. The only part you must sign by hand is your signature and the date at the bottom. When you print this form these comment lines will not appear

Once you have filled out this form, simply print it. Sign your name at the bottom and date it.

The address to mail this to along with your check (Please do NOT send cash) is found at the end of this form.

Application for Child Care Facility Accreditation

Child Care Facility Name:

Physical Address:

City:

County:

Zip:

Mailing Address same as above? Yes No

Please provide your mailing address below:

City:

County:

Zip:

Office Phone:

Fax:

Cell Phone:

E-mail:

Administrator:

Type of CCF ( Church Ministry Under a Private School )

Note: If the CCF is under a Private School, the School must be a member of FCCSPA in order for the CCF to apply for accreditation.

# of Children Enrolled:

# of Years in Operation:

Names of any agencies with which you are registered with:

Please enclose a copy of the following (please note if not available):

Letter from Church or Private School verifying that the CCF is a member of that institution
CCF Brochure

Application fees are non-refundable.

Print Name:

You must sign the form by hand, so please print, sign and date it with blue or black ink.

Signed:

Date:

Please return this form with your payment and the other mentioned items to the address below.

Please return with your application fee check in the amount of $200.00 to:

FCCPSA
P. O. Box 5100
Deltona, FL 32728-5100

If you have any questions, please call or e-mail us:

Chairman: Dr. Albert Daniel
Phone: (772) 461-9776
E-mail: Chairman@fccpsa.org