Today’s Date ______
CHECK HERE IF PROGRAM NO LONGER IN OPERATION
General Information:
Director’s Name First Provided Care
Program Name as it appears on DHS License
Do you want your program to go out to families who contact our office looking for child care? Yes No
Street Address Unit # City/Zip
Mailing Address if different from street address
County
Primary Phone 2nd Phone
E-mail Address Website
Our program is (check one):
Licensed by the Department of Human Services DHS License #______Expiration Date
Department of Education Preschool
Other
Total Desired Capacity:
How many children would you be willing to care for including all sessions?
What age of children do you accept? (Label age in weeks/months/years)
Youngest Age ______Oldest Age ______
Schools:
Name of School District your program is in
Name of nearest Public Elementary School
Transportation (check all that apply):
We are within 4 blocks of these elementary schools
We are within 1 block of a public bus route
We areon a school bus route (list schools)
Funding Program (Check any/all that apply):
Our program receives Head Start funding
Our program is funded by the Department of Education State Pre-K program
Staffing:
How many staff does your program employ? ______
Languages:
Does anyone in your program speak another language fluently? Yes No Language(s)
Does anyone in your program use Sign Language fluently? Yes No
Other Services (check all that apply):
Flexible Opening Hours
Flexible Closing Hours
Advance Phone Calls
Current Rates and Vacancies:(Please fill out even if program has no vacancies.)
Please check here if “No Fee is Charged”
Does your program charge a registration fee?
An initial fee charged by a child care program in order to enroll 1 child into the program. The fee must be charged for all children and cannot be credited towards future child care services:
Yes NoIf your program does charge a registration fee, what is the amount per child?
SESSION(list each class separately)
Circle Applicable Days / Hours / Ages / Licensed Capacity / Desired Capacity / Number Vacancies / Fee
Per Month
Mon., Tues., Wed., Thur., Fri. / 9-11:30 AM / 4 & 5 yrs / 42 / 18 / 4 / $75.00
Mon., Tues., Wed., Thur., Fri.
Mon., Tues., Wed., Thur., Fri.
Mon., Tues., Wed., Thur., Fri.
Mon., Tues., Wed., Thur., Fri.
Mon., Tues., Wed., Thur., Fri.
Mon., Tues., Wed., Thur., Fri.
Environment:
Does your program have pets? Yes No
(Only pets with fur or feathers are noted. Data about fish/aquariums is not considered.)
Cats inside
Dogs inside
Other pets inside: please identify
Outdoor pets
Would a person in a wheelchair be able to enter and exit your program independently? Yes No
Meals:
Does your program participate in the Child and Adult Care Food Program (CACFP)? Yes No
Financial Assistance:
Does your program accept children whose child care is paid for by the Department of Human Services? Yes No
Special Needs:
Do you or your staff have training or experience working with children with special needs? Yes No
(check all that apply)
Hearing Limits
Large/Small Motor Limits
Respiratory Conditions
Environment/Food/Medication Allergies
Learning Limits
Works with Specialized Services
Communication Limits
Toileting/Dressing Concerns
Diabetes
Behavioral
Accelerated Learning
Other: ______
Vision Limits
Ambulatory Limits
Nutrition/Diet Adaptations
Seizure History
Mental Health Concerns
Autism Spectrum
Profit:
Is your program organized as a 501(c)3? Yes No
What type of setting is your program located in?
Nonresidential
Faithbased
Workplace based
Public school setting
College setting
Hospital setting
Chain center
Please check all that apply:
I have questions regarding my child care program; please have my Child Care Consultant contact me.
I would like to schedule a visit with my Child Care Consultant.
I would like information on the Child and Adult Care Food Program (CACFP).
I would like to receive more information on the Quality Rating System (QRS).
I have questions regarding training; please have someone contact me.
I do not need any further information at this time.