Program Name

Provider or Contact Name

TYPE OF CARE

Child Care Center   Family Child Care
Preschool Program Only (license exempt)   School Age Only Program
Summer Camp

Street Address (location)

City      Zip

Mailing Address (if different)

City     Zip

Phone number parents should call 

Additional phone number 

E-mail address 

Website URL

Date program or license started (month and year)

What is your license ID#

What is your licensed capacity? 

If you prefer to care for fewer children than you are licensed for, what is that number? 

What are the ages you are licensed for?  From to

If you prefer to care for a narrower age group, what is it?  From to

Vacancies:  How many?    What ages?

When available? 

SCHOOL AGE INFORMATION (If you have or want school age children in your care)

What school(s) do you serve?
 

How do the children get between school and your program?

You provide transportation.

To which schools?

School bus stop near your facility. 

To which schools?

Walking distance to school. 

Which schools?

Near Public Transportation

Other (comments)

Do you provide transportation to/from the child's home?  Yes   No

Do you charge a fee for transportation?  Yes  No

If yes, how much? 

LANGUAGE

Can you, or persons on your staff, converse in a language other than English?  If yes, please list languages:

SUBSIDIES

Do you accept the DSHS subsidy (state)  Yes    No
Do you offer a sliding fee scale (fee is based on family's income level)?  Yes    No
Do you offer a reduction in cost for more that one child in a family?  Yes    No
D you provide scholarships to help families pay for child care?  Yes    No

PROGRAM DESCRIPTION

Please check the box(es) below that best describe your program.

Preschool Component - specific programming for preschool age children (3-6)
School-Age Component - specific programming for school age children
Montessori Philosophy - use approach developed by Maria Montessori.
Purchased Curriculum - subscribe to and/or use a commercially developed curriculum
Provider/Teacher Designed Curriculum - themes, activities and materials developed by provider
Emergent Curriculum- program content determined by children's interests and abilities
Private Kindergarten Onsite - Educational kindergarten program (usually at an extra cost)
Therapeutic Child Care - for children from abusive situations or with special physical/health needs

If other - please describe:

Please write a statement describing what you feel is special or unique about your program so that we may share this with families.  For example, many families are interested in learning about any training or experience that you have working with children with special needs and making your program inclusive of all children.  due to space limitations on our database, please limit your response to 35 words of less.  CCR reserves the right to edit all comments.

SCHEDULE

Check all the days that you provider care and the start time and end time each day:

Monday            Start time   End time
Tuesday           Start time   End time
Wednesday       Start time   End time
Thursday          Start time   End time
Friday              Start time   End time
Saturday          Start time   End time
Sunday            Start time   End time

Do you operate: All year long   During the school year ONLY   Summer ONLY

Do you provide:

drop in care
temporary/emergency care
before school care
after school care
rotating shift care
24 hour care
care on holidays:  which ones?

Flexibility (Please check the boxes that apply to your program)
Flexible with opening time
Flexible with closing time
Occasional Saturday care
Occasional Sunday care
Occasional evening care
Occasional overnight care
Part day care available
Part week care available
Evening care provided
Overnight care provided
School-age care with younger sibling ONLY

Is there anything you would like to share with families about your scheduling policies?

WHAT DO YOU CHARGE?

Is your standard fee the same as the DSHS rate?  Yes   No

Age 0-12 months    $ per (full time)
Age 0-12 months    $ per (part time)

Age 13-30 months  $ per (full time)
Age 13-30 months  $ per (part time)

Age 2-3 years  $ per (full time)
Age 2-3 years  $ per (part time)

Age 3-5 years  $ per (full time)
Age 3-5 years  $ per (part time)

Kindergarten    $ per (full time)
Kindergarten    $ per (part time)

1st Grade and up  $ per (full time)
1st Grade and up  $ per (part time)

Additional fees:

Application/Registration
Supplies
Late Child Pickup
Field Trips
Transportation
Enrichment Activities
Require payment in advance
Provider Paid Vacation
Provider Paid Holidays
Other (specify)

Profit Status:  Is your program certified non-profit 501(c)3?  Yes  No

ENVIRONMENT/LOCATION: (Check all that apply)

No Pets
Indoor Pets
Outdoor Pets
Covered Outdoor Play
Wheelchair Accessible
Non-smoking Premises
No Diapering Facilities
Uses Woodstove for Heat
Near Public Transportation

MEALS (Check all that apply)

Breakfast
Lunch
Dinner
Snacks
Are you on the USDA food program?  Yes   No
Will you accommodate a special diet (ex. vegetarian, food allergies)? Yes   No
Do parents provide the meals?  Yes   No
Do you charge extra for meals?  Yes   No

If yes, which ones?

PROGRAM ENHANCEMENTS:  (Please check all that apply)

Anti-bias
This is an active/activist approach to challenging prejudice stereotypes, bias, and the 'isms.'  This approach values diversity and promotes activism.  Children are taught to recognize when others are being treated unfairly based on their race, class, gender, sexual orientation, disability, or age.  they learn ways to stand up for themselves and others when faced with bias.

Gay Welcoming
Materials, philosophy and attitudes of staff welcome gay and lesbian families (enrollment forms do not ask for "mother" and "father" but "parent" or "partner"; books, posters photos and other materials reflect many kinds of families, including same sex families;  staff are accepting and welcoming of children from different kinds of families, including same sex families.

Multi-cultural Program
Recognizes cultural differences in positive and meaningful ways.  All children and staff's racial/ethnic backgrounds, gender and family styles are acknowledged.  Children are introduced to the cultures and ways of other people.  Posters, materials, books and activities representing diverse cultures are visible in the environment.  focus on cultures as a whole rather than individuals within a culture.

SPECIAL NEEDS (Do you or your staff have any training and/or experience in providing the following accommodations?  Please check all that apply)

Behavior Supervision/Supports - Program structure beyond that needed by typical children
Communication Supports - Understands/speaks sign language or accommodate assistive communication devices
Diapering/Toileting Assistance - Assistance in managing toileting or diapering of an older child
Eating Assistance - Support food preparation and feeding of older child or utilize feeding tube
Health Monitoring - Care for child with chronic condition requiring adult intervention
Medication Monitoring - Ensure child receives required medication and maintain recordkeeping
Mobility Assistance - Modify environment and/or provide assistance to child with wheelchair, crutches, or compromised mobility
Nursing Care - Access to a nurse for children requiring medical monitoring or intervention
Physical Therapy - Physical therapy credential or provide activities to support child's PT goals
Specialized Equipment - Provide and/or accommodate specialized equipment for child
Other

PROFESSIONAL INFORMATION

Education (Please send documentation)
Some ECE Credits
1 Year ECE Certificate
Child Development Associate credential (CDA)
Associates Degree (AA) in ECE or Related Field
Bachelor's Degree (BA) in ECE or Related Field
Master's Degree (MA) in ECE or Related Field
Other College Degree (specify)

FCC TEACH Participant
Center TEACH Participant
Montessori Credential

Associations/Memberships (Check all that apply)
Member of a Family Child Care Association (local/state/national)
Member of the Association for the Education of Young Children (AEYC) local/state/national
Center Director's Association
Support Group/Network
Child Care Union
Career and Wage Ladder Site
CCR&R Advisory Board
Montessori Association
Other (specify)

Organizational Structure/Affiliation  For Child Care Centers Only (Check all that apply)

Faith Based Program
Public School operation
Private School
College/Technical College
Parent Cooperative
Employer-sponsored
Military
Tribe sponsored
Church-housed (unaffiliated)

Field Trips
Facility Vehicle used
Private Vehicle used
Parents Drive
Walking field trips
Public transportation used
No field trips

TV/Video Screen Time
None
About 1/2 hour per day
About 1 hour per day
More than 5 hours per week

Enrichment Activities
Gymnastics
Extra Music
Swim Lessons
Extra Art
Theater/Drama
Parent newsletter
Parent Education
Library Storytime
Help with homework
Teaches Second Language

Advocacy
I am willing to participate in a Focus Group.
I am willing to contact a legislator.
I am willing to be contacted by the media to share my experiences about quality child care.
I can help in other ways

REFERRAL STATUS

Please list me as active on the phone referral and Internet service at www.childcare.org.
Please list me as active on the phone referral service, but not on the Internet service.
I do not wish to receive referrals at this time, but would like to receive the free newsletter and other free child care information.  I will let you know when I wish to receive referrals again.
I do not wish to receive referrals or any further information from your agency.

In order to activate your referral status, we need proof of your licensing.
Please send a copy of your license and any other required documents  to Reinette Arase. 
By mail:  Reinette Arase Child Care Resources  1225 S Weller #300 Seattle WA  98144
By FAX:  206 461-3726 Attn: Reinette Arase

For Family Child Care Providers Only

Demographic Information: Our funders require us to collect statistical information on all people we serve, including child care providers.  WE report this information as a grouping and on NOT report any individual information about any specific person.  Completing this information is optional.

Gender:  Male   Female
Age:
18-20   21-24   25-34    35-44   45-54  55-59   60-64   65-74   75+

Household Income Level:  Find your family size in the left hand column, then use the corresponding row to locate your gross household income.

Family Size           Gross household yearly income

1   $0-13,150  $13,151-21,900   $21,901-33,450   $33,951-41,609   $41,610+
2   $0-15,000  $15,001-25,056  $25,057-38,250   $38,251-47,594   $47,595+
3   $0-16,900  $16,901-28,163  $28,164-43,000  $43,001-53,484   $53,485+
4   $0-18,800  $18,801-31,307  $31,308-47,800  $47,801-59,469   $59,470+
5   $0-20,000  $20,301-33,800   $33,801-51,600  $51,601-64,219   $64,220+
6   $0-21,800  $21,801-36,300  $36,301-55,450  $55,541-68,969   $68,970+
7   $0-23,300  $23,301-38,800  $38,801-59,250  $59,251-73,719   $73,720+
8   $0-24,800  $24,801-41,300   $41,301-63,100  $63,101-78,769   $78,470+

Ethnic Background:

African American
American Indian/Alaskan Native
Asian
European American/Caucasian
Latino/Hispanic
Pacific Islander
Other

Disabled:  Yes     No

Residing in:  Incorporated King County      Unincorporated King County