Provider Name:
[ First, M.I., Last ]* |
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| Business Name: |
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| Address: * |
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| City: * |
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| Zip Code: * |
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| Mailing Address: |
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| Mailing City: |
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| Mailing Zip Code: |
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| Primary Phone Number: * |
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| Secondary Phone Number: |
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| Fax Number: |
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| Email Address:* |
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| Web Address: |
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| Newly Licensed Program |
Yes
No |
License Information
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| Family Child Care Home |
| License number: |
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| Effect Date: |
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| School and Transportation |
| Please list the names of elementary/middle schools closest to your program: |
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| 2. |
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| 3. |
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| Do you transport to these schools? |
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Yes
No |
| If yes, please complete: |
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Near Public Transportation |
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Walking Distance to School |
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Near School Bus Stop |
Languages Spoken With Children and/or Families
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Shift Information
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Rates and Enrollment Information
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| Definitions: |
- Infant: 0-11 months
- Toddler: 12-23 months
- Preschool: 24 months-until kindergarten
- Kindergarten: Attending kindergarten
- School age: Attending Grade 1-6
Please note: Community Care Licensing defines infants as 0-24 months. The purpose of maintaining correct teacher/child ratios, you must be in compliance with Licensing definition or infant; NOT the definition used by CRS to list enrollment and vacancy information. |
| Rates:* |
| Full Time |
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| Part Time |
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Enrollment:
Accepted Age Range* |
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| Meals: |
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| Policies: |
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Written contract w/parent |
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Written handbook |
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Sibling discount |
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Provider sick allowance (does provider have a plan, when ill?) |
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Provider vacation allowance (does provider mention his/her vacation time taken) |
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Child Absence allowance (does parent pay when child is out sick) |
| Other:
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| Special Needs: |
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| Affiliation: |
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| Family Childcare Setting: |
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| Census Bureau Questions: |
| Are you Spanish/Hispanic/Latino?
Yes
No |
| If not, what is your race?
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| Thank you for updating your program! Please indicate if you would like to receive any of the following information: |
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Information in Spanish/Informacion en espanol? |
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Training |
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Immunization Blue Cards |
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Information on professional membership groups |
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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: |
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