Bright Futures-Preliminary Registered Home Provider Application


		Bright Futures Child Care Information System

Skip the Navigation

Child Care Benefits

Find a Provider

Become a Provider

Preliminary Registered Home Provider Application

* Indicates Required Info

*

Last Name:

*

First Name:

Middle Name:

Suffix:

*

Date of Birth:

*

Gender:

EIN:

*

Contact Phone:

*

Home Address:

Address Line 2:

*

City:

*

Town:

*

State:

*

Zip Code:

If your mailing address is different than your home address, enter it below:

Mailing Address:

Address Line 2:

City:

Town:

State:

Zip Code:

Other Last Names Used:
(separated by commas)

Other First Names Used:
(separated by commas)

*

Have you applied for a child care license, registration, or certificate from Vermont or any other state within the last five (5) years?

If the answer to the previous question is yes, please fill out the following:

Which State?

License/Registration Outcome:

State providers have the option to submit attendance, receive notices, and perform other provider account functions through the web. If you choose to participate, you will be assigned a username and password, which you will receive at a later date. Please indicate below your preference for participating electronically, and your e-mail address if you choose to do so.

Web Site Address:

*

Electronic Participation:

E-mail:
(Required if Participating Electronically)

Copyright ©2002-2005 MAXIMUS, Inc. All rights reserved.

Page ID: LI0284 / Version: V1.95 Privacy Policy