QRIS pilot

Quality Rating and Improvement System

QRIS Pilot Year 2 Participation Application: Child Care Center (CCC)

Please submit an application for each center-based site that is licensed.

Name of Center:

Address:

Site Contact Person: Title:

Phone Number: Email:

Type of
DHS License(s): / Group Child Care Center (GCC) / DHS License Number: ______
Group Child Care Home (GCH) / DHS License Number: ______
Infant/Toddler Center (ITC) / DHS License Number: ______
Please attach a copy of each valid DHS license
Number of children program siteis licensed for:
Ages of children program accepted at this site:
Number of classrooms per type of license (GCC, IT, GCH):
Director’s name:
Is the Director primarily based on site? YES NO
Does the Director have regular teaching duties? YES NO
Is there internet access on site? YES NO
Is there access to a scanner/fax on site? YES NO

The following information is based on current enrollment. Today’s date:

Number of children currently enrolled:

Based on this current enrollment, how many children:

Receive Free/Reduced Lunch?

Have documented special needs (e.g. IFSP, IEP, Medical Report, etc.)?

Are English Language Learners (ELL)?

(OVER)
Check all that describe this site:

Faith-Based / Pre- Pre-Plus / Multi-Site
Head Start / For-Profit / Kamehameha
Early Head Start / Serves Pauahi scholars / Enrolled in HECAP
P-3 / Native Hawaiian

Check all current accreditations (please attach verification):

American Montessori Society (AMS) / Association of Christian Schools
International (ASCI)
Association of Waldorf Schools of North America (AWSNA) / Hawaii Association of Independent Schools (HAIS)/ Western Association of Schools and Colleges (WASC)
National Association for the Education of Young Children (NAEYC) / National Early Childhood Program Accreditation (NECPA)
National Lutheran School Accreditation (NLSA) / Other:

Do you currently use coaches or mentors? YES NO

Mentoring is defined as a more-experienced individual providing guidance and offering support to the less-experienced teacher. Coaching typically is more task-specific and is focused on goal-setting and achievement for the teacher or teaching team.

If YES, please describe the frequency and coaching/mentoring focus for both internal staff who provide these services and/or outside consultants who come regularly or on occasion.

Complete and submit online to . If you are not able to submit onlineplease fill out a hard copyand mail your completed form and attachments to:

QRIS Administration

University of Hawaii, Center on the Family

2515 Campus Road, Miller Hall 103 · Honolulu, HI 96822

QRIS Form 2

V2_REV 08/2013