2016-2017 SECA Membership Question Title * Date: Date / Time Date Question Title * Please enter your Contact Information Name Company Address Address 2 City/Town State/Province ZIP/Postal Code Country Email Address Phone Number Question Title * What is your SECA Membership number? Question Title * Are you licensed through the Ministry of Education? No Yes. (enter your license number) Question Title * Membership Type Child Care Centre - $200.00Any size centre, includes two memberships Group Home - $200.00More than 8 children, includes two memberships Family Home - $125.008 children and less, includes one membership Professional -$125.00An individual working in a field related to early childhood Corporate -$250.00Supportive partners Full Time Student - $50.00Enrolled in ECE or child focused studies Parent/Board Member - $50.00Not working with children Question Title * Will you purchase additional memberships? ($50.00/additional membership) No Yes (please enter how many additional memberships) Question Title * If purchasing additional memberships, please include your staff's name and email address Question Title * Would you like to purchase a Canadian Child Care Federation (CCCF) membership for $25.00? This membership is optional. Purchasing through SECA is a $40.00 savings. You must have a SECA membership for the discount Yes No Question Title * Payment Method E-transfer (Please contact the office to make arrangements) Cheque Credit Card (please enter name on the card, credit card number, expiration date and CVC/CVV number)Credit card information is destroyed once processed Done