Child Care Provider Information Form
Family and Group Family Programs
This information will be given to families requesting child care referrals[1].
Please keep us informed of any changes to your program.
Provider/Program Name:
Site Address or License No:
Phone: ( )
Do you want CCRN to give your information to parents looking for child care via intake and/or through our website?
Yes, intake and website No Web Referrals No Referrals of any type
Do you have a website? Yes (list below) No
Which school district(s) will bus children to your program?
Is your program located near a bus stop or provide transportation for children?
Transportation provided Near bus stop
Which languages are spoken fluently by your or a member of your staff? (List all that apply)
English Spanish Arabic Burmese Somali Sign Language
Other:
Is your program a Head Start/Early Head Start program? Yes No
Does your program include a state-funded UPK program? Yes No
Is your program based on Montessori or faith principles? Yes, Montessori Yes, faith-based No
Does your program provide special vacation/holiday care for school age children? Yes No
Please list the days and times your program is open
Day: Start Time End Time
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Do you want CCRN to print your rates on the profile given to parents? Yes No
Rates:
Infants: /week
Toddlers: /week
Preschool: /week
School Age: /week /hour
Please check any environment description that applies to your program: Eco-Healthy Endorsement
Fenced Pool Fireplace Gym
No Pets Wood Stove Computer
Outdoor Play Area (not fenced) Fenced Play Area Tree Nut/Peanut Free
What meals and snacks does your program provide?
Breakfast Morning Snack Lunch
Afternoon Snack Dinner CACFP
Special Meal Request Parent Provides Meals
Is your program part of CACFP? Yes No No, parents provide meals and snacks
Please check any financial assistance your program provides:
Employer Discount Multi Child Discount Parent Cooperative
Scholarship United Way Scholarship/Discount
Does your program have a county contract? Yes No, but accepts subsidy payment
No, does not accept subsidy payment
Does your program have a written contract and handbook? Yes No
Does your program have liability/accident insurance? Yes No
Does your program give parents a SSN or EIN number? Yes No
Does your program have an on-site nurse? Yes No
Please check all special needs your program can accommodate:
ADHD Asthma Autism spectrum Cerebral palsy
Deafness Developmental delay Diabetes Down syndrome
Educational Intellectual Medical care needs Moderately ill/health service
Orthopedic Seizure disorder Wheelchair access Other:
Please check all special diets your program can accommodate:
Diabetic Food Allergy Gluten Free
Kosher Style Lactose Free Vegan
Vegetarian
Please check any additional care services your program provides:
Breast Feeding Friendly Certified Early Day/Morning (earlier than 5 am) Evening (later than 7 pm)
Extended Hours Flexible Hours Part Week
Mildly Ill/Sick Overnight Weekend
Snow Days
How many years of experience in formal child care do you have?
Under 1 year 1-3 years 4-9 years
10-20 years 21+ years Family child care experience
Child care center experience Family and center child care experience
What is your education level?
High school education/diploma Associate Degree Bachelor’s Degree
ECE/child related degree Other emphasis degree Special education degree
Master’s Degree RN/LPN Health related degree
CDA
Is your program accredited?
NAFCC Not Accredited
Do you have any additional NYS certification?
NYS Children’s Program Administrator Credential Infant/Toddler Certificate Program of NYS
NYS Certified N-6 NYS Trainer’s Credential
Are you interested in being able to update your profile online? (if yes, an email must be provided) Yes No
Email:
[1] Child Care Resource Network reserves the right to modify Provider Questionnaire information to reflect accurate information.