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 Coach Social Media (Twitter, LinkedIn, Facebook) Aspire to Inspire First Up Other
Name *

First Name Last Name
Title *
Program Name *
Address *

Street Address

Street Address Line 2

City State / 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? *

Yes No
Part of a larger organization? *

Yes No
Current STAR level? *
Have you participated in either Aspire to Inspire or the Philadelphia Family Childcare Consortium? *

Yes No
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? *

Yes No
Evening hours offered? *

Yes No
Type of Program *

Family Group Center
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If DHS Certificate has been revoked or put on provisional status in the last 3 years, please specify reasons: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? *

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

First Name Last 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 Name Last 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? *

Yes No
Is the Director set up to use SharedSourcePA.org? *

Yes No
Director Support
Is there an identified staff person who is responsible during the Director's absence? *

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

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

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

First Name Last 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? *

Yes No
Which of the following funding streams do you utilize? *

ERLC Subsidy PHLpreK Pre-K Counts Early Head Start Head Start None of the above Other
What percentage of children (all ages) are receiving child care subsidy? *

None 1-25% 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?

Month Day Year
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)? *

Yes No
Will staff be provided with time away from the children to receive virtual or face-to-face coaching? *

Yes No
Does the program have a staff policy and procedure manual? *

Yes No
If the program has a manual, when was it last reviewed?
Does the program have a written mission statement? *

Yes No
When was your last contact with an ELRC Quality Coach? *
Have you had a designation visit? *

Yes No
If you've had a designation visit, please upload report:

Cancel of
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? *

Yes No
Have you had an ERS assessment? *

Yes No
If you've had an ERS assessment, please upload report:

Cancel of
Have all lead teachers had ERS training? *

Yes No
If not all lead teachers have had ERS training, how many still need it?
Have you had a PAS/BAS assessment? *

Yes No
If you've had a PAS/BAS assessment, please upload report:

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

Yes No
Have the staff been trained in PA Early Learning Standards? *

Yes No
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 *

Cancel of
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?