Name of Provider

Street Address

Address 2

City

State

Zip (ex. 06108 or 06108-0809)

Contact Person

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)

Infants

Toddlers

2.9 years and over

School-age

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

Yes No

How many part time openings?

Infants

Toddlers

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 day per hour

15 month to 2 years

per week per day per hour

2 years and over

per week per day per hour

School-age

per week per day per hour

What are your part time rates? (leave blank if you do not provide part time care)

Infants

per day per hour

15 months and up

per day per hour

2 years and over

per day per hour

School-age

per day per hour

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.

What time do you open?

What time do you close?

Are you closed in the summer?

Yes No

Which elementary school are you near?

Are you open school vacation week?

Yes No

What ages of children do you enroll in your program? (Ex: 1 month to 12 years)

From

To

If other, what?

Do you have accreditation for the following:

CDA NAFCC Montessori

Do you provide transportation?

Yes No

If yes, fee charged

Do you charge a registration fee?

Yes No N/A (don't take infants)

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

Do you have a voucher agreement with Child Care Circuit?

(for more information on becoming a voucher provider, contact the Child Care Circuit at info@childcarecircuit.org)

Yes No

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:

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

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?