a child care resource, referral & training agency

Center Based Program 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 Business:

Street Address:

City:

Zip:

Contact Person

Type of facility

(check one)

Center School-Age Program

Nursery School Private School

How many children are you licensed to provide care for? (This number is on your EEC license).

Infants Toddlers Preschool School-Age

Group Sizes:

Infants Toddlers Preschool School-Age

Child: Adult Ratio (EX. 3:1 Infants)

Infants Toddlers Preschool School-Age

As of today, do you have any full time openings in your program?

	Yes
	No

How many full time openings? Monday-Friday, full days, (school-age just have to be five 1/2 day openings)

	For Ages:	Full time openings
	Infants
	Toddlers
	2.9 years and over
	School-Age

Do you have any part time openings in your program? (1/2 days, part week).

	Yes
	No

	For Ages:	Part time openings
	Infants
	Toddler
	2.9 years and over
	School-age

What are your full time rates? (Please indicate per week, per day, or per hour

Infants	per week	per hour	per day
Toddler	per week	per hour	per day
2.9 years + up	per week	per hour	per day
School-age	per week	per hour	per day

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

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)

Is there anything specific about your rates that you would like to share with parents?

Nursery School Programs: Please describe your session options below: Ex. MTW 9-12 - 12 children & T&Th 9-12 - 12 children.

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

	Rotating				After school
	Before school				After Kindergarten
	Before Kindergarten				Temporary
	Drop in				Emergency
	Sick Care

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) are spoken in your program? (check all that apply)

	English
	Portuguese
	Vietnamese
	American Sign Language
	Khmer
	Russian
	Spanish
	Other

Please check off all that apply to your program :

	Small Groups		Academic Program
	Wheelchair Accessible		Bi-lingual classroom
	Air conditioning		Certified Kindergarten
	Enclosed outdoor play area (completely fenced/enclosed in)		Combination Infant/Toddler classroom
	Dedicated indoor play area		Religious orientation
	Pool for children		Parent Cooperative
	Play area not enclosed		Montessori philosophy

Please check off all that apply to your program :

	For Profit		Non-Profit
	Multi-site program		Employer-sponsored
	Public school affiliation		Religious affiliation
	Campus affiliation

Do you have accreditation for the following: NAEYC NSACA Montessori

Does your program use a Written Child Assessment?

Yes

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 provide transportation? Yes No

If yes, fee charged

Do you charge a registration fee?
Yes No

If yes, fee charged (Ex. $50 per year)

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
	Hot lunch
	Cold lunch
	Afternoon snack
	Special diets (if needed by child)
	Parents provide ALL food

What elementary schools are you near, and/or on the bus line?

Please list any landmark(s) near your program that would help parents find your program or decide if this area was convenient for them. Please note any highways, major streets, stores, etc.

Do you have a waiting list?
Yes No

If yes, how many children are currently on it?

Do you have a statement you would like to write which reflects your program's philosophy toward children and early education & care?

What toys are used in the EEC approved outdoor play area? (Example: riding toys, swing set, sandbox, etc)

Does your staff have any experience in caring for children with special needs? This includes any workshops/CEU's they may have taken. Please note any children cared for or workshops/courses taken for the following special needs:

	Hearing impairment
	Visual impairment
	Physical disability
	Health/Medical Condition
	Emotional/behavioral disability
	Developmental disability
	Learning disability
	Speech/language delays
	Special Circumstances

If your staff have experience with special needs, please check off all that apply relating to where they received their experience:

	EI program
	Graduate degree
	On the job training
	Own children
	Public School/766

	Undergraduate work
	Workshop/CEU's
	Other

Which of the following disability related services are available at your facility? Please check all that apply

	Adaptive equipment/Medical/Technical
	Physically accessible
	On-Site Therapy-Staff
	On-Site Therapy-Other
	Training/TA to Staff
	Dual Placement
	On-Site Medical Care
	Resources/Support to family
	Other

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 program?

	Vouchers
	Contracted slots
	DSS supportive slots
	Sibling discount
	Headstart
	Private Scholarships

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 was the program first licensed? Year only

How Would you prefer to update your information with Child Care Circuit?
phone email
If email, please include your email address:

Thank you for completing our provider listing form. Your information will begin to appear in the Child Care Circuit's on-line database in the 1st week of the month after you have sent us your information.