Child Care Program Information Form

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:
State Licensed Home or Center Voluntary Registration (homes only)  Religious Exempt Child Care Center
Certified Public School 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

Other fees:
Registration Fee Late Fee Supply Fee Extended Day Insurance  Sick Child
Summer Activity 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
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:)

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 20 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 Hours Training 13+ Hours Training Credit-based training
Some College CDA Associate degree Bachelor degree Master degree
Associate degree:
Bachelor degree:
Master degree:

Accreditation:
NAEYC NAFCC NECPA NAC NAA COA ACA - American Camp Association

Affiliation:
NAFCC NAEYC VAFCCA VAECE   Local Family Child Care Association 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: