a child care resource, referral & training agency

Family Child Care Provider Listing Form
To submit your information, please complete all fields, then click on the submit button below.  If you would like to contact someone at Child Care Circuit about your submission please e-mail inquiries to: info@childcarecircuit.org.   If you have any difficulty with this form please contact Corrine Corso at ccorso@childcarecircuit.org or at (978)722-2544.
Name of Provider: 
Street Address:
City:
Zip:
Phone:
How many children are you licensed to provide care for in your home? (This number is on your EEC license).  Not more than children
As of today, do you have any full time openings in your program?
Yes
No
How many full time openings? (Monday-Friday, full days)
Note: Total FT openings should not exceed your licensed capacity minus your current FT children in care unless you operate multiple child care shifts.
For Ages: Full time openings
Infants
15 months & up
2 years and over
Total full time openings
Do you have any part time openings in your program? (1/2 days, part week, Before school, After school).
Yes
No
For Ages: Part time openings
Infants
15 months & up
2 years and over
*School-age
*(if you have a Family Child Care Plus License)
What are your full time rates? (Please indicate per week, per day, or per hour
Infants per week  per hour   per day
15 months to 2 yrs per week  per hour    per day
2 years + up per week  per hour    per day
*School-age per week  per hour   per day
*(if you have a Family Child Care Plus License)
What are your part time rates? (leave blank if you do not provide part time care)
Infants per hour   per day
15 months to 2 yrs per hour    per day
2 years + up per hour    per day
*School-age per hour   per day
*(if you have a Family Child Care Plus License)
Do you offer a sibling discount for more than 1 family member enrolled in your program? Yes No
If yes, what is your sibling discount? (example: 10% off total, $25 off older child.  These are examples, not recommendations)
Are your rates negotiable with parents? Yes No
Is there anything specific about your rates that you would like to share with parents?
Check the days you provide day care:
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
What time do  you open?   What time do you close?
Are you flexible with your hours?   Yes No
 
What types of schedules are your willing to accept? (check as many as apply)

Full time   Part time
         
2nd Shift   3rd shift
Rotating   24 hour care
Before school   After school
             
Drop in   Temporary
Sick Care   Emergency
Are you closed in the summer? Yes No
What is your EEC License number?
What is your license expiration date?
What ages of children do you enroll in your program? (Ex: 1 month to 12 years)
From  to   of age. 
What language(s) is spoken in your home? (check all that apply)
English
Portuguese
Vietnamese
American Sign Language
Khmer
Russian
Spanish
Other
Please check off all that apply to your family environment:
Small Group
Smoke free home
Non-smoking provider
Wheelchair Accessible
Air conditioning
No pets
Cat(s)
Dog(s)
Other pets (birds, rabbits, etc.)
Enclosed outdoor play area
(completely fenced/enclosed in)
Outdoor play equipment
Dedicated indoor play area (playroom)
Pool for children
Yard not enclosed
Do you have accreditation for the following: CDA NAFCC

If "Yes" when does it expire?  _________

Do you use a Written Child Assessment?   

Yes No

If so, how often?

Annually Twice a Year

If Yes, which Child Assessment Type is Used?

Ages & Stages Creative Curriculum Developmental Continuum High Scope Child Observation Record
Work Sampling System Other

 
Do you belong to a Family Child Care System? Yes No
If yes, name the system
Do you have a voucher agreement with Child Care Circuit? Yes No
(for more information on becoming a voucher provider, contact the Child Care Circuit at info@childcarecircuit.org)

 
What meals do you provide in your program?
Breakfast
Morning snack
Lunch
Afternoon snack
Dinner
Parents provide ALL food
Special diets (if needed by child)
Are you a member of a Child Care Food Program? Yes No
What elementary schools are you near, and/or on the bus line?
Please list any landmark(s) near your home that would help parents find your home or decide if this area was convenient for them.  Please note any highways, major streets, stores, etc.
If you have pets, please list what kind, how many, and if they are indoor or outdoor pets.
Do you have a statement you would like to write which reflects your philosophy toward children and day care?
Please check off all space used in your daycare (usually they are the rooms listed on your license).
Kitchen
Living Room
Bedroom (how many)
Family Room
Dining Room
Finished Basement
Enclosed porch
Child specific playroom
What toys are used in the EEC approved outdoor play area? (Example: riding toys, swing set, sandbox, etc)
Most parents are very interested in how their children will spend the day.  What daily activities do you do with the children that you would like us to share with parents? (Example: age appropriate activities, arts & crafts, story time, circle time, etc)
Have you had any experience in caring for children with special needs?  This includes any workshops/CEU's you may have taken.  Please note any children you have cared for or workshops/courses taken for the following special need:
Hearing impairment
Visual impairment
Physical disability
Health/Medical Condition
Emotional/behavioral disability
Developmental disability
Learning disability
Speech/language delays
Special Circumstances
If you have experience with special needs, please check off all that apply relating to where you received our experience:
EI program
Graduate degree
On the job training
Own children
Public School/766
     
Undergraduate work
Workshop/CEU's
Other
Please share any experience you have had in relation to child care and Early Childhood Education.  Parenting experience counts as do any workshop/courses you have taken (check all that apply).
High School Diploma or GED
2 year degree - child related
2 year degree - non child related
4 year degree - child related
4 year degree - non child related
Master's degree - child related
Master's degree - non child related
Administrator's credentials
Special needs experience/training
Child care center experience
ECE college courses
ECE workshops
Nursing Degree: RN LPN
Parenting experience
Please check all that apply to your Family Child Care:
Adult pool on premises
Approved Assistant Full time Part Time On Call
Car not used regularly
Apartment
Condominium
Multi-Family home
Single Family home
Large Group Home license
Family Child Care Plus license (6+2)
Please check off all that applies to your program:
Uses nearby park
Provides transportation
Near public transportation
Fields trips taken
On Public School bus route
   
Accepts cloth diapers
   
Provides infant equipment
What subsidies do you offer in your Family Child Care program?
Vouchers
Sibling discount
   
Are you willing to speak with expectant parents?  There will be no obligation for you to accept referrals. Yes No N/A (don't take infants)
When were you first licensed? Year only
If you do not have current openings in your program, please let us know what month you anticipate any, how many, and for what age.
Month(s) anticipated:
How Would you prefer to update your information with Child Care Circuit?
phone email
If email, please include your email address:
Please be aware that Child Care Circuit will only be conducting regular updates via e-mail. This is also how we send out information on available Trainings being offered.
The following information is for statistical purposes only and will not be shared with parents.  They are part of an ongoing effort to collect data on the need for affordable health care for independent family child care providers
What type of health care do you currently have?
Family Plan Individual Plan Children only None
How is your health care obtained?
On my own Spouse's Plan Mass Health Chamber of Commerce
Medicare Other Group Plan Second Job N/A
Would you like help in this area? Yes   No