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 Name
Last Name
Contact Person's Title
*
Director
Owner
Administrator
Other
Facility Name
*
Location Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County
*
Do you have a different mailing address?
Primary Phone
*
-
Area Code
Phone Number
Secondary Phone
-
Area Code
Phone Number
Email
*
example@example.com
Website
Child Care Type
Child Care/ Child Development Program
Preschool (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 Enrolled
CDA/CCP Credential
Associates Degree in Early Childhood
Bachelors Degree in Early Childhood
Masters Degree on Early Childhood
Certificate of Mastery
Director's Credential
Associates Degree-Non Child Related
Bachelors Degree- Non Child Related
Masters Degree & Up-Non Child Related
Is your program accredited?
ACSI
COA
NAFCC
APPLE
NAEYC
CARF
NECPA
NAC
AdvancED
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-Time
Part-Time (30 hours or less per week)
Drop in (hourly pay)
After School
Before School
Year Schedule: Full Year
Year Schedule: Summer Only
Year 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 Year
School Year
Summer 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 Subsidy
Sliding Scale
Private Pay
Indian Contract
SSI/Special Needs
Choctaw
Chickasaw
Cherokee
Creek
Other
Excluding subsidy, does your program receive Tribal Funding to operate?
Yes
No
If yes, list tribe in "other"
Other
Care Setting
Church
Workplace
Free Standing
House
Townhome
Mobile Home
Private School
Duplex
Apartment
Building Public School
Organization Type
For Profit
Non-Profit
Environment (check all that apply)
No Pets
Smoke Free
Wheelchair Accessible
ADA Accessible Outdoor Play Equipment
Classroom Video Monitoring
Secure Entry
Pool/Lake
Non-Carpeted
Fenced Yard
Are you part of the USDA Food Program?
Yes
No
Other
Transportation (check all that apply)
Transportation Provided
No Transportation
Near Public Transportation
Transportation To/From Home
Walking Distance to School
Transportation to/From School
Close to School Bus Stop
School 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)
Behavioral
Developmental
Medical
Physical
Special Needs
Add/ADHD
Allergies
Apnea (infant) Monitor
Asthma
Autism
Diabetes
Emotional/Behavioral Disabilities
Mentally Disabled/Learning Disabled
Mentally Retarded/Learning Disabled
Physical Disabilities
Seizures
Sensory Impared
Are you or do you have staff who are Hispanic or Latino?
Yes
No
Other
Do you or the staff speak fluent Spanish?
Yes
No
Other
How many Direct Care staff do you typically employ?
Star Level
Rows
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:
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