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General Information

First Name: Last Name:
Business Name:

Mailing

Street Address Unit #
City: State Zip Code -

Contact

Primary Phone ( ) ext.
Secondary Phone ( ) ext.
Fax ( )
Email Address
Website

License Information

License ID Expiration Date:

License Type

Lic. Child Care Center Class I Lic. FCC Home Class II Lic. FCC Home
LLEP FCC Home - Rel LLEP FCC Home - Non Rel LLEP in Child's Home
LLEP Child Care Facility Minimum Standards Register Ministry
Other - See Comments    

Capacity
Total Licensed
Total Desired
Total Vacancies as of
 
 

Accepted Age Range

From years months weeks
To years months weeks
Number of Shifts/Session

School Information

School District: Elementary Schools/Catchement School Transportation

Transportation

Transportation Provided Walking Distance to School Near Public Transportation

Languages

English German Vietnamese African - Other American Indian
Spanish French Japanese Middle East - Other European - Other
Latin Russian Chinese American Sign Asian - Other
Portuguese Italian Korean Other - See Comments  

Transportation Needs

To-From Child's Home to Provider On School Bus Route To-From Activity Other - Comments
To-From Providers to School On Public Tran. Route No Transportation  
Walking Distance To-From School To-From Parent's Work    
 
 
 

Day Care Provided

Shift General Information
Shift Name
Accepts Children
Duration No Fee Charged
  Drop In Temp/Emergency
Info Last Updated Before School After School
Rotating 24-Hour
  Open Holidays  
Day Start Time End Time
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Rates
Age Group (Age Range)
Hourly
Daily
Weekly
Infant 1 Age Group (SAC All Others)
Infant 2 Age Group (0 - 12 Months)
Toddler 1 Age Group (13 - 23 Months)
Toddler 2 Age Group (24 - 25 Months)
Preschool 1 Age Grp (3 - 4 Years)
Preschool 2 Age Grp (5 Years)
School Age 1 Group (Kindergarten)
School Age 2 Group (SAC Before / After School)

Additional Fees

Drop-In Fee Sick Care 24 Hour Fee
Transportation Fee Meals / Snack Fee Supplies Fee
Enrollment / Registration Fee Activity Fee Late Fee
Other Fee - See Comments    

Population Information

Age Group (Age Range)
Des Cap
Enroll
Infant 1 Age Group (SAC All Others)
Infant 2 Age Group (0 - 12 Months)
Toddler 1 Age Group (13 - 23 Months)
Toddler 2 Age Group (24 - 25 Months)
Preschool 1 Age Grp (3 - 4 Years)
Preschool 2 Age Grp (5 Years)
School Age 1 Group (Kindergarten)
School Age 2 Group (SAC Before / After School)
 
 
 

Environment

Enclosed Outdoor Area No Pool or Waterfront Pool or Waterfront Gym
Indoor Play Area No Pets Pets Handicap Accessible
Separate Care Area Smoke Fee No Smoking during CC Other - See Comments

Meals

Breakfast Morning Snack Lunch Special Meal Request
Afternoon Snack Dinner Evening Snack Other - See Comments
4 CS's provide service Other CACFP Meals / Snacks Not Provided

Meal Service (Only required for 4CS's provided meal service)

Meal Type Occ Svc Shift Begin Time End Time
Mon
Tue
Wed
Thru
Fri
Sat
Sun
Breakfast Yes No
AM Snack Yes No
Lunch Yes No
PM Snack Yes No
Supper Yes No
Night Snack Yes No

Philosophy

Thematic Montessori Religion Based Other - See Comments
Reggio Developmental Appropriate Academic  
High / Scope ABEKKA    

Policies

Written Contract Provider Vac. Allowance Family Vacation Allowance Other - See Comments
Written Handbook Provider Sick Allowance Child Absense Allowance  
May Give Rates Two Week Notice Holiday Allowance  

Special Skills

NAEYC NAFCC Validator / Trainer Mentor Other - See Comments
CDA Advisor IPICC Project        

Safety

CPR Certification First Aid Training Child Abuse Prevention Other - See Comments
CPR Infant Universal Precautions On-Site Nurse  
Baby Safety Shower Security Cameras    

Special Needs

ADD/ADHD Apnea Monitor Asthma Treatments Sensory Disability
Autism Disorder Catheter Cerebral Palsy Special Diets
Cognitive Disability Down's Syndrome Feeding Tubes Tracheotomy
Health/Medical Disability Hearing Impairment Injections Visual Impairment
Language Delay Muscular Dystrophy Physical Disability Other - See Comments
Diabetic Behavioral    

Training

Orientation Training (Old) Risk Watch Second Helping Other - See Comments
Spec. Needs Awareness Spec. Needs Skills Building West Ed  
Start-up Workshop Baby Safety Learn Not To Burn  

Experience

Under 1 Yr 1-5 Yr Experience 5-10 Yrs Experience Other - See Comments
10-20 Yr Experience +20 Yr Experience CC Center Experience  
First Steps Special Ed. Co-ops    
 
 
 

Education

HS Diploma / GED Some College EC / CC Some College Other Other - See Comments
CDA AA / AS in Early Childhood AA / AS Degree Other  
Health Degree BA / BS in Early Childhood BA / BS Degree Other  

Accreditation

NAEYC NAFCC NSACA Other - See Comments

Affiliation:
Local CC Network ILCCA IAEYC Other - See Comments
NAEYC NAFCC NSACA  

Operation Child Care

Operation Child Care    

Family Child Care

Family Care Settings
Wages

Benefits

No Health Coverage Pays Medical Insurance Pays Dental Insurance
Health Coverage From Other Contributes to Retirement Pays for Training / Edu.
Budgets for Time Off Contributes to Disability  
Other - See Comments    

Comments