.:child care program information form:.

Contact Person (Director/Provider):
Business Name (if applicable):
For profit Not for profit Public Faith based
Physical Location (street address):
City: State: Zip:
County:
Mailing Address (if different):
Phone:
Cell or Other Phone:
Fax:
Email:
Website:

Type of Care:

Child Care Center Family Child Care Provider Preschool Program Only Parent's day out program
Schoolage Program Only Summer Camp Program After school mentoring/tutoring
Head Start Program (Head Start Funding) Virginia Preschool Initiative (State Pre-K Funding)

Type of Regulation:

License ID# (if licensed)
State Licensed Home or Center Family Child Care System Licensed
Voluntary Registration (homes only) DSS Locally Approved Home or Individual
Religious Exempt Child Care Center Certified Public Preschool
Unregulated Home or Individual State Exempt Instructional/Recreational
Military Approved Family Child Care Home Other - Please Specify

Ages of children accepted for care: Licensed capacity: Desired capacity:
Schools served for Before & After Care - Elementary: Middle:
Transportation services that you provide, if any:
Languages spoken, other than English:

Days care is available (please check all that apply):

Mon Tues Wed Thur Fri Sat Sun
Hours care is available: 24 Hour care

Rates / Fees

Age Hourly Daily Full-time weekly Before school only After school only Before & After school
Infant 1 (0-12 months)      
Infant 2 (13-15 months)      
Toddler 1 (16-32 months)      
Preschool 1 (2-3 years)      
Preschool 2 (4-5 years)
Schoolage 1 (5-9 years)
Schoolage 2 (10 & older)

Other fees:

Registration Fee Late Fee Supply Fee Extended Day Fee Insurance
Sick Cild Fee Summer Activity Fee Transportation Fee Holiday Fee Meal Fee

Services provided

(please check all that apply):
Full time (30 or more hrs per wk)
Part time (29 or fewer hrs per wk)
Drop in (not enrolled for regular care)
Temporary/ Emergency/ Backup care 		Before school
After school
Field trips
Holiday care 		Rotating Shift Care
Sick child care
Evening care
Overnight care 		Respite care
Open all year
Open summer only
Open school year only

Environment:

(please check all that apply)
Non-smoking
Air conditioning
Fenced yard		 Wheelchair accessible
No indoor pets
No outdoor pets		 No pool
No weapons

 No wood-burning stoves
No kerosene heaters

Meals:

Check meals served (Please indicate a per meal cost if additional fees are charged)
Breakfast $ AM Snack $ Lunch $
PM Snack $ Dinner $ Evening Snack $
Parent provides meals USDA Food Program participant Special meal request

Financial Assistance:

(Check all that apply:)
Accepted: Public Funds State Subsidy (DSS funds) Private Subsidy/Scholarships
Provided: Scholarships Sliding Fee Scale Other

Policies:

Written Contract Handbook Multi-child Discount Liability Insurance
Provider Sick Allowance Provider Vacation Allowance Child Absence Allowance

Safety:

CPR Certified First Aid Certified Medication Administration Certified Health-Related Degree On-Site Nurse

Special Needs:

(Check all that apply)
Adaptive Special Equipment Asthma/Respiratory Allergies ADD/ADHD Autism/Aspergers
CP/Neuralgic/Seizure Disorders Developmental Delay Cognitive Diabetes Down Syndrome
Post Traumatic Stress Disorder Medical ODD Physical Social/Emotional
Learning disabled resources Space for therapy PT/OT Experience/Training or desire to provide care

Experience:

Refers to the Center Director or Family Child Care Provider
Under 1 year 1 to 3 years 4 to 9 years 10 to 20 years Over 21 years
Family Child Care experience Child Care Center experience

Training/Education:

Refers to the Center Director or Family Child Care Provider (Specify area of study)
High School Education 0-12 hrs training 13+ hrs training Credit-based training Some College
CDA Associate degree in Bachelor degree in Master degree in

Acceditation:

NAEYC NAFCC NECPA NAC NAA COA ACA

Affiliation:

NAFCC NAEYC VAFCCA VAECE Local Family Child Care Assoc Local AEYC

Child Advocacy Issues:

Will visit legislators Will contact legislators Will write letters Will make phone tree calls

Enrollment Requirements:

Orientation Physical-Health Record Medical Authorization Parent Information Proof of Birth

Curriculum:

ABEKA Creative Curriculum High Reach High Scope Houghton Mifflin Pre-K
Montessori Mother Goose Pinnacle Reggio Other

DO NOT include my information for:
Web Referrals Referrals to Parents Rates Training Information mailings

I certify that the information on this form is true and correct, and that I am legally operating within the laws and child care regulations of the Commonwealth of Virginia. (Section §63.2-1727 of the Code of Virginia prohibits any person from operating a family day home if he, or if he knows that any person who resides, is employed by, or volunteers in the home, is a convicted sex offender or has a founded complaint of child abuse or neglect within or outside the Commonwealth.) I agree to enroll children without regard to race, color, religion, sex, age, veteran status, national origin, disability or political affiliation. I agree to notify (CCRR) within 30 days of any changes in the child care facility’s phone number, address, regulation or certification status.

By submitting this form, I agree to the terms listed above.

Please enter today's date as your signature: