EQUIP Provider Application

EQUIP Provider Application
Please fill out this application as completely as possible. All of the requested information will be useful in the determination of our initial cohort. This application can be saved to be finished at a later time.
General
Where did you hear about EQUIP*

From my ELRC Quality CoachSocial Media (Twitter, LinkedIn, Facebook)Aspire to InspireFirst UpAnother Director/OwnerOther
Name*

First NameLast Name
Title*
Program Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Website
Facebook Page
Instagram Page
MPI Number*
(can be found on Program Certification)
Federal Employer Identification Number (EIN)*
(will be your personal SSN if business is a sole proprietorship)
Tax-exempt?*

YesNo
Part of a larger organization?*

YesNo
Current STAR level?*
Have you participated in either Aspire to Inspire or the Philadelphia Family Childcare Consortium?*

YesNo
Please describe any coaching or support the program is currently receiving, including the name of the project and organization offering the project.*
Operations
Hours of Operation (M-F)*
Years in Operation*
Weekend hours offered?*

YesNo
Evening hours offered?*

YesNo
Type of Program*

FamilyGroupCenter
Which months of the year is your program in operation?*
Describe summer programming (if any):
If DHS Certificate has been revoked or put on provisional status in the last 3 years, please specify reasons:
If the program offers services for school-age children, how many school-age children are served?
General comments:
Owner/Executive Director
Is the Program Director also the Owner/Executive Director?*

YesNo
(If No, then please complete the following. If Yes, skip to Director.)
Owner/Executive Director Name

First NameLast Name
How often is the Owner/Executive Director on site?
How often do the Owner/Executive Director and Director meet to discuss issues related to quality (e.g., curriculum, best practices, STARs, staffing, etc.)?
Director
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
How many years as Director at this site?*
Total years in ECE?*
If the Director is "in ratio" on a regular basis, approximately how many hours per week on average?*
Will the Director be available to meet with the Coach and ELRC Quality Coach at least two times per month?*

YesNo
Is the Director set up to use SharedSourcePA.org?*

YesNo
Director Support
Is there an identified staff person who is responsible during the Director's absence?*

YesNo
(If No, then please complete the following. If Yes, skip to Program Support.)
Name

First NameLast Name
Title
Email
example@example.com
Phone Number
Please enter a valid phone number.
Program Support
Who is the Director's immediate supervisor (if any)?

First NameLast Name
Title
Email
example@example.com
Phone Number
Please enter a valid phone number.
Who is responsible for STARs implementation in this program?*

First NameLast Name
Title*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Who is responsible for coaching staff and staff supervision?*

First NameLast Name
Title*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Governance & Finance
Current year operating budget:*
Do you have an annual audit?*

YesNo
Which of the following funding streams do you utilize?*

ERLC SubsidyPHLpreKPre-K CountsEarly Head StartHead StartNone of the aboveOther
What percentage of children (all ages) are receiving child care subsidy?*

None1-25%26-50%51-75%76-100%
If the program uses software to manage data for children, families, staff, billing, and/or attendance, what is the name of that software?
If the program is governed by a Board of Directors, when was the last Board Meeting?

MonthDayYear
Date
Governance and Finance comments:
Classrooms
Classrooms List click (on "+" to add more rows)*
Staffing
Please complete the Staff Roster Grid supplied to you separately. Include all leadership and support staff as well as teaching staff.
Leadership & Systems
Describe the methods used to communicate with staff:*
How frequently are staff meetings held?*
What time of day/week are staff meetings held?*
If you use an agenda for staff meetings, what are some items found on a typical agenda?
Does your staff receive regular planning time (without supervising children)?*

YesNo
Will staff be provided with time away from the children to receive virtual or face-to-face coaching?*

YesNo
Does the program have a staff policy and procedure manual?*

YesNo
If the program has a manual, when was it last reviewed?
Does the program have a written mission statement?*

YesNo
When was your last contact with an ELRC Quality Coach?*
Have you had a designation visit?*

YesNo
If you've had a designation visit, please upload report:

Cancelof
As part of this initiative, you will be receiving two assessments, the Environmental Rating Scale (ERS) and either the Program Administration Scale (PAS - for centers and commercial-based groups) or Business Administration Scale (BAS - for family and group providers in a residence). Are you committed to working with your coach on create goals based on these assessments and working to improve practices?*

YesNo
Have you had an ERS assessment?*

YesNo
If you've had an ERS assessment, please upload report:

Cancelof
Have all lead teachers had ERS training?*

YesNo
If not all lead teachers have had ERS training, how many still need it?
Have you had a PAS/BAS assessment?*

YesNo
If you've had a PAS/BAS assessment, please upload report:

Cancelof
What are the top three challenges the program is experiencing in achieving STAR 3?*
Does the program have reliable Internet, scan, and fax capabilities?*

YesNo
Have the staff been trained in PA Early Learning Standards?*

YesNo
Please describe anticipated systems changes (if any) for the next year:
How are staff utilizing PA Early Learning Standards?*
How are you using your current CQI plan?*
How often do staff observe and assess children's development?*
Financial Statement

Please upload your program’s financial statement for the last complete fiscal year. Your financial statement may also be called a “statement of profit and loss,” and “income statement,” or an “income and expense statement.” The financial statement is not the program’s budget, but instead itemizes revenue and expense for a 12-month period.
File Upload*

Cancelof
Attestation Statement
I certify that all responses provided in this application are accurate, complete, and current as of this date.

Clear
Any last comments?
Additional Comments:
Should be Empty:

EQUIP Provider Application

General

Operations

Owner/Executive Director

Director

Director Support

Program Support

Governance & Finance

Classrooms

Staffing

Leadership & Systems

Financial Statement

Attestation Statement

Any last comments?