Intake Form
Name of individual licensed to operate program
*
First Name
Last Name
Program location
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-mail
*
example@example.com
Best time To call
Main phone number
*
Format: (000) 000-0000.
Cell phone number
*
Format: (000) 000-0000.
Number of children in your care?
*
Hours of Operation?
*
Hours of operation?
*
i.e. 8 am to 4 pm
Age range of children in your care?
*
i.e. 2 months to 4 years old
How long has your Day Care been open?
*
Preliminary Intake Questions
l. Are you the only employee for this Family Day Care site? If no, how many other employees are on site daily?
*
2. Do you currently read to the children? If yes, how does your site obtain books?
*
4. Are you willing to attend training sessions on how to promote literacy in young children?
*
Yes
No
5. What is the best way for you to receive your books?
*
Pick Up
Delivery
6. Please use the space provided to briefly describe the types of activities you provide for the children:
*
Date
*
-
Month
-
Day
Year
Date
Signature
*
Submit
Should be Empty: