OPT OUT - I do not wish to complete this form and understand that my program will not be referred to families by the ELC. (School Readiness and VPK providers contracted with the ELC are required to complete this form.) Early Learning Coalition of Escambia County Name of Person Filling Out Coalition (ELC)/Agency: Date Form Completed: 3300 N. Pace Blvd., Suite-210 Form: Do you wish to have your Pensacola, FL 32505 program referred to families YES NO seeking child care listings from the ELC? Business Name: (as on License or Exemption) Doing-Business-As Name: Owner Name: Director Name: City: County: Location Address: Zip Code: City: County: Mailing Address: Zip Code: Fax: Provider Type Center FCCH Large FCCH School-age Only Private School Public School one): Do you want your house number and street name to appear on referral lists to families? Family Child Care Home Yes No Only: Legal Status Licensed Registered Exempt (check one): Exemption Type Religious Exempt Camp Non Public School Public School School Age one): Affiliation Not For Profit: Yes No – DCF/Local Licensing ID: Expiration Date: Master School ID (MSID): Federal ID No: (Public and Private Schools only) 1. ACCREDITATION - Are you accredited by an accrediting agency? (Check all that apply) A copy of your certificate is required in order for accreditation to be listed. Accrediting Agency Effective Date End Date ASSOCIATION OF CHRISTIAN SCHOOLS INTERNATIONAL ASSOCIATION OF CHRISTIAN TEACHERS AND SCHOOLS
OPT OUT - I do not wish to complete this form and understand that my program will not be referred to families by the ELC. (School Readiness and VPK providers contracted with the ELC are required to complete this form.) Name of Person Filling Out Form: Coalition (ELC)/Agency: Early Learning Coalition of Escambia County 3300 N. Pace Blvd., Suite-210 Pensacola, FL 32505 Date Form Completed: Do you wish to have your program referred to families seeking child care listings from the ELC? YES NO Business Name: (as on License or Exemption) Doing-Business-As Name: Owner Name: Director Name: Location Address: City: County: Zip Code: Mailing Address: City: County: Zip Code: Fax: Provider Type one): Center FCCH Large FCCH School-age Only Private School Public School Family Child Care Home Only: Do you want your house number and street name to appear on referral lists to families? Yes No Legal Status (check one): Licensed Registered Exempt Exemption Type one): Religious Exempt Camp Non Public School Public School School Age Affiliation – Not For Profit: Yes No DCF/Local Licensing ID: Expiration Date: Master School ID (MSID): (Public and Private Schools only) Federal ID No: 1. ACCREDITATION - Are you accredited by an accrediting agency? (Check all that apply) A copy of your certificate is required in order for accreditation to be listed. Accrediting Agency Effective Date End Date ASSOCIATION OF CHRISTIAN SCHOOLS INTERNATIONAL ASSOCIATION OF CHRISTIAN TEACHERS AND SCHOOLS
CCRR_Provider_Update_Form_ELC_address_2014-15ELC_1.docx