.:vacancy and rate quarterly update form:.

All fields in green must be completed before this form can be submitted.

Form Completed by: Date:
Contact Person (if different than above): Phone:
Business name (if applicable): E-mail address:
Street Address:
City: State: Zip:
No Vacancies - Check here if you do not have any current vacancies and just complete the rate information.

Full-time: Includes all care provided a minimum of 30 hours per week 5 days and 6 or more hours per day.
Part-time: Includes all care provided less than 30 hours per week or fewer than 5 days and less than 6 hours per day.

Current number of vacancies   Weekly Rate Information
For statistical purposes only - your best
estimate of current full-time vacancies
Full-time
weekly
Part-time
weekly
Before school
weekly
After school
weekly
Before & After
school weekly
No Age Preference
         
0-12 months
13-15 months
16-23 months
2-3 years
4-5 years
5-9 years
10 & older
Special Needs 13+