Fall 2024 Provider Update Form/Road Trip

Fall 2024 Provider Update Form
Your Name *

First NameLast Name
Thank you for taking a few minutes to share about your program.
Child Care Program Name*
K8#*
Does your program have a website? If so, please share the link.*
Center Director or FCCH Owner's Name*

First NameLast Name
Child Care Program Email*
example@example.com
Child Care Program Phone Number*

Area CodePhone Number
PHYSICAL Address (if different than mailing)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Age range you offer care for? *
How many children total are currently enrolled in your program?*
Do you accept? *click all that apply*

Private PayDHS SubsidyTribal SubsidyMilitary SubsidyOther
How many INFANTS in your care are private pay?*
How many TODDLERS in your care are private pay? *
How many 2 YEAR OLDS in your care are private pay?*
How many 3 YEAR OLDS in your care are private pay? *
How many 4 YEAR OLDS in your care are private pay?*
How many 5 YEAR OLDS in your care are private pay? *
How many SCHOOL AGE children in your care are private pay?*
What are your FULL TIME PRIVATE PAY WEEKLY rates for Infants (0-12mo)? *
What are your FULL TIME PRIVATE PAY WEEKLY rates for Toddlers (12mo-24mo)? *
What are your FULL TIME PRIVATE PAY WEEKLY rates for 2yo? *
What are your FULL TIME PRIVATE PAY WEEKLY rates for 3yo? *
What are your FULL TIME PRIVATE PAY WEEKLY rates for 4yo? *
What are your FULL TIME PRIVATE PAY WEEKLY rates for 5yo? *
What are your FULL TIME PRIVATE PAY WEEKLY rates for School Age (6+)? *
What days of the week do you provide care?*

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
What are your daily hours of operation?*
If you offer transportation, please list the schools you transport to/from:
Do you offer care for children with special needs?*

YesNoOther
Do you or any of your staff speak fluent Spanish?*

YesNoOther
Do you participate in CACFP aka "The Food Program" - if so, which one?
How many OPENINGS do you currently have for INFANTS?*
How many OPENINGS do you currently have for TODDLERS?*
How many OPENINGS do you currently have for 2yo?*
How many OPENINGS do you currently have for 3yo?*
How many OPENINGS do you currently have for 4yo?*
How many OPENINGS do you currently have for 5yo?*
How many OPENINGS do you currently have for School Age (6yo+)?*
What do you love about Great Plains Child Care Resource & Referral?
Thank you for taking the time to complete this form!

We appreciate all you do!

Rachel, Lisa, Jennifer, Athena & Emmy
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