Membership Enrollment Application

To become a member of Early Learning NH, fill out the form below and pay by credit card, or download the enrollment form and mail it in with your payment to the Early Learning NH office. Note that there are a number of different levels to become a member. Please select the level you desire.

Fields marked with a red asterisk (*) are required.

* First Name:
* Last Name:
* Organization
* Address
* City/Town
* State
* Zip
Home Phone
* Work Phone
* E-mail
Web Site URL

PROVIDER members are child care facilities (public or private, profit or non-profit) that provide direct early child care and education services to children.

Family Provider - $30.00
Center Provider - $75.00

CORPORATE CHAMPIONS are businesses, consultants, and other entities that have a stake in the bottom line benefit of providing high quality accessible child care for children and working parents.

Corporate Champion - $250.00

CHILD CARE CHAMPIONS are individuals with an academic or personal interest in the mission of child care and who are not eligible in any of the above categories.

Child Care Champion - $50.00
Parent - $20.00

Please list me in the following category (check all that apply):

School Age Program
Elected Official
Family - Group
Elementary School
State Official
Send information about Conference?
Receive Newsletter
Food Care Program Sponsor
Advocacy Taskforce
Ages Cared For? No. of children served:
Hours Open No. of Staff:
How did you hear about us?
Can other members search for your listing?

Early Learning NH
Two Delta Drive, Concord, NH 03301
Phone: (603) 226-7900   Fax: (603) 226-7290   info@earlylearningnh.org