a child care resource, referral & training agency

Center Based Program 

Monthly Update 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:
E-mail:
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
If any of the information listed below has changed since your last update, please indicate your new information. 
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
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 closed in the summer? Yes No
Near what elementary school? 
Are you open school vacation week?  Yes No
What ages of children do you enroll in your program? (Ex: 1 month to 12 years, 1 month) Note: If you just put 12 years, a parent searching for a child age 12 years and 1 month will not get your program as a referral.
From to years of age.
What language(s) are spoken in your program? (check all that apply)
English
Portuguese
Vietnamese
American Sign Language
Khmer
Russian
Spanish
Other
Do you have accreditation for the following: NAEYC NSACA Montessori
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)
Do you have a waiting list?
Yes No

If yes, how many children are currently on it? 

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
Relative's work
Undergraduate work
Workshop/CEU's
Other
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)
How Would you prefer to update your information with Child Care Circuit?
phone email
If email, please include your email address:
Is there anything else you would like to share?

Thank you for completing our provider update form.