Tell Us Your Story

First name: *

Last Name: *

Email: *

Phone Number:

Address Line 1:

Address Line 2:

City:

State: *

Zip Code: *

Type of Child Care Used:

Family Child Care Home

Center-Based Care

Church-Based Care

Family Member

Is your Child Care program/provider licensed?:

yes

no

I don't know

Age of child(ren): ex:2, 3, 5

Where is your child care located:

urban

rural

Attach a File to this story:

NACCRRA is requesting permission to print, re-use, reproduce or otherwise publish your material in electronic as well as print format in our publications including but not limited to reports, periodicals, articles, Congressional briefs and testimony, NACCRRA websites, letters and Op-Ed opinions. If you are willing to grant NACCRRA permission to use your material, proper attribution will be given as indicated below. To grant permission, please type your name in the signature space listed below.

Can we use your name in connection with your story?: *

yes

no

May we make editorial edits to your story with no changes to concept? : *

yes

no

Signature: *

Date: *

Parents