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| CONTACT INFORMATION |
| Name: | |
| Business Name: | |
| Address: | |
| City, St, Zip: | |
| Home Phone: | |
| Alternate Phone: | |
| Fax: | |
| Email: |
| PROGRAM INFORMATION |
| Type of Home Provider (please select all that apply) |
| Licensed Type A with State Day Care Licensing | |
| Certified Type B with local County Department of Jobs & Family Services | |
| Registered Type B with Child Care Choices |
| How many children are you legally allowed to care for during one shift? |
| Ages of children willing to care for: |
| Youngest: | Oldest: |
| Days and Hours of Operation |
| Days of Operation (select your days of operation) |
Start Time (be sure to indicate AM or PM) |
End Time (be sure to indicate AM or PM) |
|
| Monday | |||
| Tuesday | |||
| Wednesday | |||
| Thursday | |||
| Friday | |||
| Saturday | |||
| Sunday |
| Do you provide care? |
| Full-time only: | |
| Part-time: | |
| Full-time & Part-time: |
| Environmental Issues |
| Non-smoking during care hours | |
| Non-smoking environment | |
| No Pets | |
| Outdoor Pets; Specify what kind: | |
| Indoor Pets; Specify what kind: | |
| Pool | |
| Fenced Yard | |
| Wheelchair accessible | |
| Trampoline | |
| Other; Specify: |
| MEAL INFORMATION |
| Which of the following meals do you provide during your daycare hours of operation? |
| Breakfast | AM Snack | Lunch | PM Snack | Supper | Special Diet |
| Are you involved with the Child and Adult Care Food Program (CACFP)? |
| Yes: | No: |
| SPECIAL NEEDS |
| Can you provide for any of the following Special Needs (you must be trained in those areas)? |
| Emotional and/or Behavioral | Medical conditions | Speech and/or Hearing | Physical and/or Mobility | MR/DD | Visual | Allergies and/or Asthma |
| SPECIAL SERVICES provided within your setting |
| Head Start | Preschool program | Do you transport
to/from School? Yes; Specify which school(s): No |
| Please indicate your level of education (check all that apply): |
|
| RATE INFORMATION |
| Age of child |
Hourly Part-time |
Hourly Full-time |
Weekly Full-time based on 45 hours |
| 0 - 23 months old | $ | $ | $ |
| 24 months - 3 years | $ | $ | $ |
| 3 - 5 years, but not in school | $ | $ | $ |
| 5 - 10 years | $ | $ | $ |
| 11 - 15 years | $ | $ | $ |
| Do you offer a Sibling Discount? Yes No |
| Any comments regarding rate information: |
| VACANCIES
(please indicate how many spaces available for each shift) |
CURRENT ENROLLMENT (please indicate how many total children you currently have enrolled for each age group) |
| 1st Shift | 0 - 23 months |
| 2nd Shift | 24 months - 3 years |
| 3rd Shift | 3 - 5 years, not in school |
| 5 and over, in school |
| Comments regarding your daycare business: |