Child Care program Information (New Program)

Child Care program Information

Fill out the following form to register your program with our Child Care Resource & Referral. If you're already registered with us, you may use this form to update your information. As an update only enter in information that is new.
Contact Person's Name*

First NameLast Name
Contact Person's Title*
Facility Name*
Location Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County *
Do you have a different mailing address?
Primary Phone*

Area CodePhone Number
Secondary Phone

Area CodePhone Number
Email*
example@example.com
Website
Child Care Type

Child Care/ Child Development ProgramPreschool (additional program within facility)Head Start (additional program within facility)Early Head Start (additional program within facility)State Pre-K (additional program within facility)Camp (additional program within facility)
Certificate/Degree/Education (based on Center Director/Owners Education)

CDA/CCP Currently EnrolledCDA/CCP CredentialAssociates Degree in Early ChildhoodBachelors Degree in Early ChildhoodMasters Degree on Early ChildhoodCertificate of MasteryDirector's CredentialAssociates Degree-Non Child RelatedBachelors Degree- Non Child RelatedMasters Degree & Up-Non Child Related
Is your program accredited?

ACSICOANAFCCAPPLENAEYCCARFNECPANACAdvancED
Schedule-Days Child Care is provided (example indicate 6:00 am as 06:00 am)*
Type of Child Care offered (check all that apply)*

Full-TimePart-Time (30 hours or less per week)Drop in (hourly pay)After SchoolBefore SchoolYear Schedule: Full YearYear Schedule: Summer OnlyYear Schedule: School Year Only
Age Accepted Age Range: Youngest (months)
Age Accepted Age Range: Oldest (months)
Total Desired Capacity
Total Licensed Capacity
Schedule Duration

Full YearSchool YearSummer Only
Age Group
Vacancies
Please list your part-time fees according to age group on a weekly basis (if applicable)
Please check all forms of financial assistance that you offer or accept.

DHS SubsidySliding ScalePrivate PayIndian ContractSSI/Special NeedsChoctawChickasawCherokeeCreekOther
Excluding subsidy, does your program receive Tribal Funding to operate?

YesNoIf yes, list tribe in "other"Other
Care Setting

ChurchWorkplaceFree StandingHouseTownhomeMobile HomePrivate SchoolDuplexApartmentBuilding Public School
Organization Type

For ProfitNon-Profit
Environment (check all that apply)

No PetsSmoke FreeWheelchair AccessibleADA Accessible Outdoor Play EquipmentClassroom Video MonitoringSecure EntryPool/LakeNon-CarpetedFenced Yard
Are you part of the USDA Food Program?

YesNoOther
Transportation (check all that apply)

Transportation ProvidedNo TransportationNear Public TransportationTransportation To/From HomeWalking Distance to SchoolTransportation to/From SchoolClose to School Bus StopSchool Bus Delivers to Facility
Public Schools you transport to or that deliver to facility (list all below)
Special Needs Inclusion (program staff that have education and training and accept children w/special needs)

BehavioralDevelopmentalMedicalPhysical
Special Needs

Add/ADHDAllergiesApnea (infant) MonitorAsthmaAutismDiabetesEmotional/Behavioral DisabilitiesMentally Disabled/Learning DisabledMentally Retarded/Learning DisabledPhysical DisabilitiesSeizuresSensory Impared
Are you or do you have staff who are Hispanic or Latino?

YesNoOther
Do you or the staff speak fluent Spanish?

YesNoOther
How many Direct Care staff do you typically employ?

Star Level

	1 Star	1 Star+	2 Star	3 Star	4 Star	5 Star
Star Level

List any school districts/elementary school(s) that are within close proximity
Is there anything else about your program that you would like us to know? (Other languages spoken, special skills etc.)
Emergency Contact Information:
Should be Empty: