Update Child Care Program : Provider Update
First Name *
Last Name *
Job Title
Program Name *
Address *
Address Line 2
City *
State *
Zip Code *
Phone (With Area Code) *
Fax
Email *
Type Of Program *	Center Family Child Care School Age Program Nursery School/Preschool Camp Other
If Other, Please Explain
Ages of Care (Check All That Apply) *	Infant Toddler Preschool Kindergarden School Age Other
If Other, Please Explain
Do you have any vacancies in your program?
Infant Openings
Toddler Openings
Preschool Openings
Kindergarden Openings
School Age Openings
Schedule of Care Hours	Full Time Part Time Both Other
If Other, Please Explain
Hours and Days of the week the program is open.
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Sessions	Year Round School Year Only Summer Only Other
If Other, Please Explain
Are Meals Provided?	Yes No
If so, which ones?
Transportation Provided?	Yes No
Is the program close to public transportation?	Yes No
If so, what kind?
Is the program near school bus routes	Yes No
If so, which ones
Nearest Elementary School(s)
Approximate Distance
Fees	Hourly Daily Weekly Monthly Yearly Other
Please list your full-time fees according to age group
Please list your part-time fees according to age group
Do you offer a sibling discount?	Yes No
If so, please explain
Please list all forms of financial assistance that you offer or accept.
Are All staff/providers trained in first aid?	Yes No
Please discribe staff education, degrees, and experience.
Please discribe staff experience with special needs
Is there anything else about your program that you would like us to know?
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