Day Care Center and School Age Programs

Child Care Provider Information Form

Day Care Center and School Age Programs

This information will be given to families requesting child care referrals[1].

Please keep us informed of any changes to the program.

Provider/Program Name:

Site Address or License No:

Phone: ()

Do you want CCRN to give the information to parents looking for child care via intake and/or through our website?

Yes, intake and website No Web Referrals No Referrals of any type

Does the program have a website? Yes (list below) No

Which school district(s) will bus children to the program?

Is the program located near a bus stop or provide transportation for children?

Transportation providedNearbus stop

Which languages are spoken fluently by a member of the staff? (List all that apply)

English SpanishArabic Burmese Somali Sign Language

Other:

Is the program a Head Start/Early Head Start program? Yes No

Does the program include a state-funded UPK program? Yes No

Is the program based on Montessori or faith principles? Yes, Montessori Yes, faith-based No

Does the program provide special vacation/holiday care for school age children? Yes No

Please list the days and times the program is open

Day:Start TimeEnd Time

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Do you want CCRN to print the rates on the profile given to parents? Yes No

Rates:

Infants: --/week

Toddlers: --/week

Preschool: --/week

School Age: /week/hour

Please check any environment description that applies to the program: Eco-HealthyEndorsement

Fenced Pool Fireplace Gym

No Pets Wood Stove Computer

Outdoor Play Area (not fenced) Fenced Play Area Tree Nut/Peanut Free

What meals and snacks does the program provide?

Breakfast Morning Snack Lunch

Afternoon Snack Dinner

Special Meal Request Parent Provides Meals

Is the program part of CACFP? YesNo No, parents provide meals and snacks

Please check any financial assistance the program provides:

Employer Discount Multi Child Discount Parent Cooperative

Scholarship United Way Scholarship/Discount

Does the program have a county contract? Yes No, but accepts subsidy payment

No, does not accept subsidy payment

Does the program have a written contract and handbook? Yes No

Does the program have liability/accident insurance? Yes No

Does the program have an on-site nurse? Yes No

Please check all special needs the program can accommodate:

ADHD Asthma Autism spectrum Cerebral palsy

Deafness Developmental delay Diabetes Down syndrome

Educational Intellectual Medical care needsModerately ill/health service

Orthopedic Seizure disorder Wheelchair accessOther:

Please check all special diets the program can accommodate:

Diabetic Food Allergy Gluten Free

Kosher Style Lactose Free Vegan

Vegetarian

Please check any additional care services the program provides:

Breast Feeding Friendly Certified Early Day/Morning (earlier than 5 am)Evening (later than 7 pm)

Extended Hours Flexible Hours Part Week

Mildly Ill/Sick Overnight Weekend

Snow Days Holiday

How many years of experience in formal child care does the program director have?

Under 1 year 1-3 years 4-9 years

10-20 years 21+ years Family child care experience

Child care center experienceFamily and center child care experience

What is the education level of the program director?

High school education/diploma Associate Degree Bachelor’s Degree

ECE/child related degreeOther emphasis degree Special education degree

Master’s Degree RN/LPN Health related degree

CDA

Is the program accredited?

NAEYC Not Accredited Other:

Does any staff have additional NYS certification?

NYS Children’s Program Administrator Credential Infant/Toddler Certificate Program of NYS

NYS Certified N-6 NYS Trainer’s Credential

Are you interested in being able to update the profile online? (if yes, an email must be provided) Yes No

Email:

[1] Child Care Resource Network reserves the right to modify Provider Questionnaire information to reflect accurate information.