YMCA Childcare Resource Services Child Care Center Program Update 2006

YMCA CRS Provider Information

Child Care Program Update Form

* Required

Director's Name: *
[ First, M.I., Last ]

Business Name:*

Site Address: *

Site City: *

Site Zip Code: *

Mailing Address:

Mailing City:

Mailing Zip Code:

Primary Phone Number: *

Secondary Phone Number:

Fax:

Email Address:

Web Address:

Newly Licensed Program	License Exempt Child Care Center
Yes No	Yes No

License Information

Infant/Toddler License number:

Effect Date:

Preschool License number:

Effect Date:

School-Age License number:

Effect Date:

School and Transportation

Please list the names of elementary/middle schools closest to your program:

Do you transport to these schools?

Yes No

If yes, please complete:

School Name	Transport AM	Transport PM
1.
2.
3.

Languages Spoken With Children and/or Families

English	Chinese	Vietnamese
Spanish	Korean	American Sign Language
Tagalog		Other

Shift Information

Day	Start Time	End Time
Monday-Friday
Saturday
Sunday

	Full year	School weeks only
	Before school	Summer only
	After school	Temporary/Emergency (mildly ill)
	24-hour	Rotating (work schedule changes)
	Open holidays

Rates and Enrollment Information

Rates:*

Full Time

Age Range	Hourly	Daily	Weekly	Monthly
Infant
Toddler
Preschool
Kindergarten
School-age

Part Time

Age Range	Hourly	Daily	Weekly	Monthly
Infant
Toddler
Preschool
Kindergarten
School-age

Enrollment:*

Age Range	License capacity	Full time capacity	Part time capacity	Vacancy date	Currently enrolled
Infant
Toddler
Preschool
Kindergarten
School-age

Philosophy:

Montessori	Waldorf	RIE
High Scope	Reggio Emilia	Other learning programs

Special Needs:

Sensory	Adaptive Equipment
Health/Medical	Developmental Disability
Disability-Vision	Sensory Disability-Hearing
Learning Disability	Emotional/Behavioral Disability
Physical Disability	Communication/Language Delayed
Cognitive Disability	Other:

Center Staff Education (Check All that apply) :

High School education	Some college, child related
Some college, other emphasis	Associate degree, child related
Associate degree, other emphasis	Bachelor's degree, child related
Bachelor's degree, other emphasis	Master's degree, child related
Master's degree, other emp hasis	Child Development Associate certified

Child Care Setting:

For-profit	Workplace-based	Head Start
Non-profit	Parent participation	Other:
Faith-based	State Preschool	Accredited site

Program Structure:

School-age program

Other:

Census Bureau Questions:

Childcare Center only:

Number of persons on staff who are Spanish/Hispanic/Latino:

Mexican/Mexican American/Chicano

Other Spanish/Hispanic/Latino

Puerto Rican

Cuban

Number of persons on staff whose race is:

White	Vietnamese	Other Pacific Islander
Black	Asian Indian	Guamanian or Chamorro
Chinese	Native Hawaiian	American Indian or Alaska Native (what tribe)
Filipino	Other Asian	Other race
Japanese	Samoan

Thank you for updating your program! Please indicate if you would like to receive any of the following information:

CRS Childcare Communiqué

Information in Spanish/Informacion en espanol?

Training

Immunization Blue Cards

Information on professional membership groups

Library Appointment:

Resource library
Toy lending library
Resources in Motion mobile van

Most convenient day and time:

Topic of interest:

You will be contacted to confirm an appointment date.

Nearest office:

Mission Valley

National City

San Marcos