WSFCCA MEMBERSHIP APPLICATION 2018-2019
NAME ____________________________________________________
BUSINESS NAME ________________________________________________
ADDRESS _________________________________________________
CITY ____________________________ STATE _____ ZIP _________
PHONE _____________________ EMAIL: ______________________
STARS ID _________________________________________________
FULL MEMBER (LICENSED) ____ ASSOCIATE MEMBER (RETIRED) ___
CHOOSE YOUR CHAPTER _____________________________________
DUES FOR THAT CHAPTER $_____________
ACCIDENTAL MEDICAL INSURANCE (THIS IS NOT LIABILITY)
$50.00 per year for up to 12 children. October 1, 2017 - Sept 30, 2018
This accidental/medical insurance is a secondary coverage to the parent's insurance. It will pick up what the parent's insurance does not cover or all costs (up to the maximum policy limit) if there is no other insurance.
Contact Joan Aarts immediately should an accident happen and you want to file a claim. 360-790-4211, Email: [email protected]
Chapter Dues $___________
Accidental/Medical $___________
TOTAL DUE $___________
Visit our
website to register online and pay thru PayPal OR print this membership application and
mail along with check to:
Joan Aarts, WSFCCA Membership,
561 Burnaby Ave SE, Olympia, WA 98501.
Make checks payable to WSFCCA.
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