Filling out the form below will send e-mail directly to the Child Care Action Council's Resource & Referral Staff. Accurate information about your program helps us to serve you better. The information is also used for statistical reports about child care in our community and statewide. You can choose to update all of your information or just your current openings.


General Information

Licensee/Contact Person Name

Business Name

Type of care provided (please mark one)
Licensed Family Child Care
Licensed Center Care
Preschool Only (lic. exempt)
School Age ONLY
Summer Camp

Date program started

Facility Street Address

Facility City Facility Zip

Mailing address (if different)

Mailing City Mailing Zip

Phone # parents can call Additional phone #

Fax

E-mail address

Website

STARS Training ID#

Are you licensed?
Yes No

License ID (see top left corner of your license)

License Expiration Date

Licensed for a total of children

Accepted age range: from youngest to oldest

Desired total capacity: children, from youngest to oldest

Total number of openings today

School District where program is located

Elementary School nearest you

Is the Elementary School Walking Distance from the program?
Yes. No.
Is the program near public transportation?
Yes. No.


If you have or want school age children in your care:

School kids may attend

Do you transport kids to/from school?
Yes. No.
If yes, which school(s)?

Does a school bus stop near your facility?
Yes. No.
If yes, from which school(s)?

Do you have any additional comments about school age kids in your care?


Please mark all languages spoken by you or your staff.

English Spanish
American Sign Language Russian
Vietnamese Cambodian
Japanese Cantonese
German Korean
Samoan Other

Please mark all subsidies you accept/offer.
DSHS
Homeless
Multi-child Discount
Sliding Scale (based on family's income)
Keystone Crisis Nursery
Other, please describe

Program Model
Preschool Component School-Age Component
Montessori Philosophy Purchased Curriculum
Provider/Teacher Designed Emergent Curriculum
Private Kindergarten Therapeutic Child Care
Other Model

Business Days and Hours:

Monday from AM PM to AM PM
Tuesday from AM PM to AM PM
Wednesday from AM PM to AM PM
Thursday from AM PM to AM PM
Friday from AM PM to AM PM
Saturday from AM PM to AM PM
Sunday from AM PM to AM PM

Do you accept children:
Both full- and part- time
Full-time only (35 hours+)
Part-time only

Do you operate:
all year long
during the school year ONLY
during summer ONLY

Do you provide, mark all that apply:
drop-in care
temporary/emergency care
before school care
after school care
retating shift care
24-hour care
Care on the following holidays

Family Child Care capacity and openings (columns do not add to to total capacity):
Age Range Maximum #
Licensed for		 Maximum #
Accepting		 # of Openings
(AM or PM)		 Date of Openings
Infant
0-12 months
FT PT
Toddler
1-2 years
FT PT
Toddler
2-3 years
FT PT
Preschool
3-5 years
FT PT
Kindergarten
FT PT
Grades 1 & up
FT PT

Center Care capacity and openings (columns do not add to to total capacity):
Age Range Maximum #
Licensed for		 Maximum #
Accepting		 # of Openings
(AM or PM)		 Date of Openings
Infant
0-12 months
FT PT
Toddler
1-2 years
FT PT
Toddler
2-3 years
FT PT
Preschool
3-5 years
FT PT
Kindergarten
FT PT
Grades 1 & up
FT PT

What to you charge per day, week or month?
full-time  
part-time
Age 0-12 months $ per   $ per
Age 13-24 months $ per   $ per
Age 2-3 years $ per   $ per
Age 3-5 years $ per   $ per
    school days     full days
Kindergarten $ per   $ per
1st Grade & up $ per   $ per

Is your standard fee the same as the DSHS rate?
Yes. No.

Additional fees:
Application $ Supplies $
Late Pickup $ Field Trip $
Transportation $ Enrichment Activities $
Provider Paid Vacation Provider Paid Holidays
Req. Advance Payment

Tell us about your program:
Would you provide respite (relief) care for children with special needs outside your regular business hours?
Yes. No.

In your program considered not-for-profit by the IRS?
Yes. No.

Environment
no pets indoor pets
outdoor pets covered outdoor play area
wheelchair accessibility non-smoking (always)
wood stove used for heat (during or outside program hours)

Meals Served
breakfast lunch
dinner snacks
parents provide meals extra charge for meals
additional meals extra USDA Food program participant
will accommodate family diet preferences

Special Skills
10-Hour STARS Trainer 20-Hour STARS Trainer
Trained Mentor Consultant
Building Blocks for Family Child Care Trainer

Special Needs (training or experience providing for needs not typical to child's age):
Behavior Supervision/Supports Diapering/Toilet Assistance
Health Monitoring Nursing Care
Mobility Assistance Physical Therapy
Communication Supports Eating Assistance
Medication Monitoring Specialized Equipment

Accreditation (to have these listed as part of your profile, you must submit a copy of the certificate with an expiration date):
NAFCC (Family Child Care) NECPA (Center Care)
NAEYC (Center Care) NAC (Center Care)
MSAC (Montessori Center Care)> ACSI (Faith-based Center Care)
NAA (After School Care) Military Certification

Affiliation
FCC Association Support Group/Network
Career & Wage Ladder CCR&R Advisory
Montesori Association CCAC Member

Would you be willing to advocate on child care issues by:
Contacting Legislators Contacting Legislators
Testifying at Legislative hearings Participating in focus groups
Receiving mailings about advocacy opportunities

Schedule Flexibility
Opening Time Closing Time
Occasional Saturday Occasional Sunday
Occasional Evening Occasional Overnight
School Age w/Younger Sibling Not Flexible
Evening past 6:30 p.m. Overnight past 3:00 a.m.
Weekend (Sat. Sun. Both)


Organizational Structure
Is your program linked with any of the following (check all that apply)?
church/faith based org. public school
private school college/vocational tech
parent cooperative employer-sponsored
Military Tribe
limited to certain clients, describe

Do you take children on field trips? If yes, how to they get there?
facility vehicle provider private vehicle
parents drive walking
public transportation no field trips

How much time do children in your care spend watching TV or videos and/or playing video games?
None About 1/2 hour per day
About 1 hour per day More than five hours per week

Do you offer any of the following?
gymnastics music
swim lessons art
theatre parent newsletter
parent education homework assistance
library storytime
Other, please explain

Who is your DEL Licensor?
Sharon Bell Jean Orton-Elders
Kathy Schroeder Deb Harris
Charlotte Dedman Linda Robertson
Cynthia Anstiss

Communication Preferences:
How can CCAC contact you (check all that apply)?
email. mail. phone.

How would you like to receive CCAC's newsletter and other printed materials?
email only. mail only. both.

Are you interested in receiving our newsletter and other printed materials in Spanish?
Spanish only. English only. both.


Please note: It is our policy to refer parents to providers by matching location, type of care and ages of children as primary criteria. The Americans with Disabilities Act (ADA) prohibits discrimination against people with disabilities. Therefore, we refer children with disabilities to any provider matching a family's primary child care needs, regardless of training or experience. Under the ADA, all providers must individually assess a child’s needs to determine reasonable accommodations for inclusion. If you would like more information or support in caring for children with disabilities, please contact CCAC at 754-0810 or 800-845-0956.

I have read and agree to the above Resource & Referral Policies.




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Spotlight

For more information about finding and choosing quality child care, healthy child development, other CCAC Programs, Community Resources and more, click
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Child Care Action Council Parent Guide.

 

Child Care Action Council Parent Guide

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