Today’s Date ______

  CHECK HERE IF PROGRAM NO LONGER IN OPERATION

General Information:

Name Co Provider

Business Name (if applicable) First Provided Care

Do you want your name to go out to families who contact our office looking for child care? Yes No

Street Address Unit # City/Zip

Mailing Address if different from street address

County

Primary Phone 2nd Phone

E-mail Address Website

License Type: Legal Capacity:

  Child Care Home 5

  Child Care Home Accepting Child Care Assistance 5

  Child Development Home A 8

  Child Development Home B 12

  Child Development Home C1 8

  Child Development Home C 16

Total Desired Capacity:

How many children (including your own children that are not yet in school) are you willing to care for at any one time?

(Your own school-agers are not included in your registration capacity unless they are being home-schooled.)

What age of children do you accept? (Label age in weeks/months/years)

  Youngest Age ______Oldest Age ______

Vacancies
Shifts / # of Openings / Ages of openings
DAYTIME (5am-6pm)
EVENING (6pm-12am)
OVERNIGHT(12am-5am)

Schools:

Name of School District you reside in

Name of nearest Public Elementary School

Transportation (check all that apply):

  I transport children to these elementary schools/preschools

  I live within 4 blocks of these elementary schools

  I live within 1 block of a public bus route

  I live on a school bus route (list schools)

Languages:

Does anyone in your program speak another language fluently? Yes No Language(s)

Does anyone in your program use Sign Language fluently? Yes No

Other Services (check all that apply):

  Flexible Opening Hours

  Flexible Closing Hours

  Advance Phone Calls

  Crisis Care

  Sick Care

Child Care Provided:

Hours of Operation
Days / Open / Close
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Shift General Information:

I wish to care for (Check One):

  Full Time (Over 28 hrs/wk)

  Part Time (Less than 28 hrs/wk)

  Both

I provide care (Check One):

  Full Year

  School Year

  Summer Only

Check All that Apply:

  I’m willing to provide Drop-In Care

  I’m willing to provide temporary/emergency care

  I provide before school care

  I provide after school care

  I can accommodate rotating schedules

  I’m open on legal holidays

Does your program charge a registration fee?

An initial fee charged by a child care program in order to enroll 1 child into the program. The fee must be charged for all children and cannot be credited towards future child care services:

Yes No If your program does charge a registration fee, what is the amount per child?

Does your program offer a multi-child discount?

Yes No If yes, please give details

What are Your Current Rates?
(only fill in boxes that apply to you)
Age Group: / Hourly / Daily / Weekly / Other
Infants (Birth - 12 Months)
Toddlers (13 - 23 Months)
2 Yr Olds
3 Yr Olds
4, 5 and ½ Day Kindergarten
Before/After School
Full Day School Age
Please note: we only use rate information for statistical purposes
Comments/Additional/Information About Rates:

Environment:

Does your program have pets? Yes No

(Only pets with fur or feathers are noted. Data about fish/aquariums is not considered.)

  Cats inside

  Dogs inside

  Other pets inside: please identify

  Outdoor pets

Would a person in a wheelchair be able to enter and exit your program independently? Yes No

Meals:

Does your program participate in the Child and Adult Care Food Program (CACFP)? Yes No

Financial Assistance:

Does your program accept children whose child care is paid for by the Department of Human Services? Yes No

Special Needs:

Do you or your staff have training or experience working with children with special needs? Yes No

(check all that apply)

  Hearing Limits

  Large/Small Motor Limits

  Respiratory Conditions

  Environment/Food/Medication Allergies

  Learning Limits

  Works with Specialized Services

  Communication Limits

  Toileting/Dressing Concerns

  Diabetes

  Behavioral

  Accelerated Learning

  Other: ______

  Vision Limits

  Ambulatory Limits

  Nutrition/Diet Adaptations

  Seizure History

  Mental Health Concerns

  Autism Spectrum

Education (check the highest level you have completed):

  Less than High School/GED

  1 Yr Vocational-Child Related

  2 Yr Associates-Other

  Masters or Higher

  High School/GED

  1 Yr Vocational-Other

  Bachelors-Child Related

  CDA

  2 Yr Associates-Child Related

  Bachelors-Other

How did you hear about CCR&R? ______

Please check all that apply:

  I have questions regarding my child care program; please have my Child Care Consultant contact me.

  I would like to schedule a visit with my Child Care Consultant.

  I would like information on the Child and Adult Care Food Program (CACFP).

  I would like to receive more information on the Quality Rating System (QRS).

  I have questions regarding training; please have someone contact me.

  I do not need any further information at this time.