Director First Name:

Director Last Name:

Business Name:

I would like to be on your referral list and have current openings.

I would like to be on your referral list when I have openings, but I am currently full in all classrooms.

I do not ever want to be on your referral list.

I would like my price information to be available to parents.

Street Address (Please list the coordinates of any street names):

City:

State:

Zip Code:

Address:

City:

State:

Zip Code:

Primary Phone: ( )

Secondary Phone: ( )

Fax: ( )

E-mail Address:

Website:

How many children are you licensed for:

What is your desired capacity at one time:

What is the youngest age child you accept:
yrs mos

How many total vacancies do you have:

What is the oldest age child you accept:
  yrs mos

I provide transportation to and from school

The children walk to and from school

0 -11 months

12 - 23 months

2 years

3 years

4-5 years (pre-kindergarten)

Kindergarten

Grade 1-6

Under 2 years (part time)

2 - 3 years (part time)

Over 2 years (evenings)

I provide care full time

Start Time

End Time

I provide care part time

Monday

I provide care for children year round

Tuesday

I provide care only during the school year

Wednesday

I provide care only during the summer

Thursday

I accept children on a drop in basis

Friday

I accept children before and after school

Saturday

I can provide temporary or emergency care

Sunday

I accept children whose schedule rotates

I am open for all the major holidays

0-11 months

12-23 months

2 years

3 years

4-5 years

Kindergarten

School-Age

Registration

Transportation

Late pick up

Late payment

Returned check

Field Trips

Materials

Food

Desired Capacity

Licensed
Capacity

Full Time Vacancies

Part Time Vacancies

Child Adult Ratio

Max Group Size

0 - 11 months

12- 23 months

2 years

3 years

4- 5 years

Kindergarten

School-Age

I never allow smoking on the premises including after hours

There is public Transportation (UTA) near my facility

I have pets that interact with the children in my program

I have pets that are kept separate from the children in my program

I have age-specific toys and activities for children

There is a seat belt for each child in the vehicle I use when transporting

I have an out door play area that is fenced

I have outside play equipment

I have a swimming or wading pool

I am near a public park I take the children to

I offer an educational preschool program for 3-5 year olds

I offer instruction in a second language

I take the children in my program on field trips

I provide help with homework to school age children

I offer other special activities(please explain):

I have internet access available to children

I have a web-cam in my program

I offer a private Kindergarten

I provide breakfast

I provide an am snack

I provide lunch

I provide a pm snack

I provide dinner

I can accommodate special meal requests

Parents must provide all meals

Parents must provide special meal requests

Parents must provide formula for infants

I belong to a Food Program

I offer developmentally appropriate activities

This is a Montessori program

My program has a religious component

I require parent involvement or participation in my program

My program partners with a Head Start Program

This is a Reggio Emilia program

I want my program listed in a printed referral directory with the CCR&R phone number

I want my program listed in a printed referral directory with its own phone number

I do not want my program listed in a printed referral directory

I offer a sliding fee scale and can change my rates based on the families ability to pay

I give a discount to families who have more than one child enrolled in my program

I give a discount to employees of some corporations (list which corporation):

I offer tuition scholarships to families

I give a discount to members of a particular organization

I do not charge families if their child misses a day

I have a written contract that parents sign upon enrollment

I have written policies and procedures which parents receive a copy of

I have emergency exit routs posted in my program

I have a written emergency plan

There is someone in my program at all times with a current CPR certificate

There is someone in my program at all times with a current First Aid certificate

All adults who prepare of serve food in my program have a current Food Handlers Permit

There is someone in my program who has a health related degree such as nursing

I have liability insurance for my child care program

I have vehicle insurance that covers passengers

I have a firearm (gun) on the premises

I have a firearm (gun) that is in a locked safe (not a cabinet)

I have a firearm (gun) that has a trigger lock

I am able to evaluate each child’s needs on an individual basis

I have experience with the items I’ve checked below

I have training with the items I’ve checked below

Orthopedic disabilities

Visual impairments

Hearing impairments

Emotional/Behavioral disability

Developmental Delays

Learning Disabilities

ADHD/ ADD

Asthma

Autism

Cerebral Palsy

Diabetes

Downs Syndrome

Epilepsy

Feeding Tubes

Seizures

Spina Bifida

Multiple Sclerosis

Muscular Dystrophy

Children who need oxygen

0-11 months

1 year

2 years

3 years

4 years

5-9 years

10-14 years

15-19 years

20+ years

I have less than a High School Diploma

I have a High School Diploma

I have a CDA or CCP

I have has some college courses in Child Development or Early Childhood

I have a one year college certificate in Child Development or Early Childhood

I have an Associates degree in Child Development or Early Childhood

I have a Bachelors Degree in Child Development or Early Childhood

I have a graduate degree in Child Development or Early Childhood

I have college experience in another field

NAFCC

NAEYC

NCCA

NSACA

In progress

NAFCC

PFCCA

NAEYC

UAEYC

NCCA

UPCCA

NSACA

USACA

STAEYC

I would be willing to provide legislative advocacy information to parents

I would be willing to have a legislator visit my program

I would be willing to write advocacy letters to political representatives

I would be willing to testify to the legislature on behalf of children

I would be willing to participate in a list serv to receive advocacy information

I can occasionally provide care at least ½ hour before my regular opening time

I can occasionally provide care at least ½ hour after my regular closing time

I can occasionally provide care during a swing shift (7:00 pm – midnight)

I can occasionally provide care during a grave yard shift (midnight – 6:00 am)

I can occasionally provide care on a Saturday

I can occasionally provide care on a Sunday

I can occasionally provide care on holidays

I can occasionally provide care for a child who is mildly sick

I have a special license that allows me to care for sick children

I can occasionally provide evening or overnight care

Non-residential (most centers)

Faith-based

Workplace-based

School-based

Drop In/ Seasonal Resort