NECPA Enrollment Form

Program Name*

Street Address*

Street Address Address Line 2 City State ZIP Code

Is this also your shipping address?*

Yes
No

Shipping Address*

Street Address Address Line 2 City State ZIP Code

Director*

First Last

Program Email Address*

Phone Number*

Fax Number (If applicable)

Owner Name*

Is Your Program Center-Based or Home-Based?*

Center-Based
Home-Based

Are you a multi-site family home provider?*

Yes
No

NECPA MULTI-SITE FAMILY CHILD CARE PROVIDER POLICY
1. One program Director must facilitate the operations of the program as a whole.
2. The sites must be within “walking-distance” to one another so that the Director is able to access each site daily and at a moment's notice.
3. The program’s multi-site enrollment candidacy will be evaluated upon completion of your enrollment form and the completion of the below questionnaire.

Multi-Site Question 1: Please provide the addresses of each location/building below.*

Multi-Site Question 2: Are the locations/buildings within walking distance of one another?*

Yes
No

Multi-Site Question 3: Does each location/building function as one unified program?*

Yes
No

For example: Infants are served at one location and preschool at another location next door, but each unique location serves as part of a whole unified program serving the community.

Multi-Site Question 4: Is there ONE director that oversees the whole program?*

Yes
No

Alternate Contact Name*

Alternate Contact Phone Number*

State License or Registration Number*

Please Upload a Copy of Your State License*

Multi-Site Provider - Secondary License Upload

Please upload your second location's license here.

License Capacity*

Please enter the total license capacity noted on your state license.

Number of Classrooms*

Number of Buildings*

Is your program enrolled with Paths to QUALITY?*

Yes
No

By participating in accreditation, you MAY be eligible for Accreditation Financial Assistance through the Indiana Accreditation Project (IAP). You must be enrolled with Paths to QUALITY to be eligible to apply for IAP support. Learn more about Paths to Quality here https://indianaspark.com/paths-to-quality.

Is your program enrolled with the Indiana Accreditation Project (IAP)?*

Yes
No

Learn more about the IAP program here: https://inaeyc.org/indiana-accreditation-project.

Is your program participating in Child Care Aware of America's Military Fee Assistance program?*

Yes
No

Learn more about the program here: https://www.childcareaware.org/fee-assistancerespite/feeassistancerespiteproviders/feeassistance.

Is your program working with a third party consultant? Would you like to authorize them to communicate with NECPA on your behalf?*

Yes
No

Consultant Name

First Last

Consultant Email

Enrollment Fee

NECPA Enrollment Fee - License Capacity 7-60 Children ($385)*

Price: $385.00

Fee based upon license capacity, total will automatically update with selection.

NECPA Enrollment Fee - License Capacity 61-120 Children ($413)*

Price: $413.00

Fee based upon license capacity, total will automatically update with selection.

NECPA Enrollment Fee - License Capacity 121-240 Children ($495)*

Price: $495.00

Fee based upon license capacity, total will automatically update with selection.

NECPA Enrollment Fee - License Capacity 241+ Children ($550)*

Price: $550.00

Fee based upon license capacity, total will automatically update with selection.

Additional Products (Optional)

Would you like to purchase additional materials?

Additional Products

Select All
National Child Care Association Program-Wide Membership
Additional NECPA Self Assessment Instrument (One copy is included with application fee)
Additional NECPA Standards Book (One copy is included with application fee)
Additional Documentation Box Labels (One set is included with application fee)
Parent Flyers (Flyer designed to acquaint parents with the accreditation process and its value, 25 per order)

NECPA Process Understandings

1) I understand that the NECPA accreditation is valid for three years with the submission of an Annual Report during each of the accreditation years.
2) I understand that a NECPA Accredited program is required to maintain NECPA standards, requirements and physical plant under which the program is awarded accreditation.
3) I understand that the NECPA Commission reserves the right to revoke the accreditation of any program found to be out of compliance with the NECPA standards.
4) I understand that the enrollment period lasts for two years from the date of the NECPA Enrollment Letter issued by the NECPA Office and that the NECPA Verification Visit Request Form must be submitted within that time period.

Please print your full name to agree to the above NECPA Process Understandings*

Indiana Accreditation Financial Assistance Understandings

I understand that in order to apply for Accreditation Financial Assistance with the INAEYC Indiana Accreditation Project (IAP), I must:
1) Be enrolled and in good standing with Paths to QUALITY™ at any level,
2) Submit to IAP through their online application, an open enrollment invoice from NECPA,
3) Submit my IAP scholarship application within 30 days of my NECPA enrollment submission.

I also understand that if my application for Accreditation Financial Assistance is denied for any reason, I will be responsible for the NECPA accreditation fees.

Please print your full name to agree to the Indiana Accreditation Financial Assistance Understandings*

Payment Details

Fees are non-refundable and subject to change without prior notice.

Total Amount (Will update automatically.)

$0.00

Please note, the correct payment will appear in this section after the license capacity has been added. Please ensure the program's license capacity in the form is the same as the capacity noted on your state license. If there is a difference in the required fee due and the fee paid, an invoice will be sent for remittance. Only enrollments PAID IN FULL are able to be fulfilled.

Credit Card

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Name

This field is for validation purposes and should be left unchanged.