New Provider Referral Questionnaire

Please complete this form and check all applicable boxes below.

Your submission is missing important information and/or contains errors. Please correct the omissions/errors highlighted in red below and resubmit the form.

Type of care:* (check only one)

Contact Information:

Same as Above

Capacity Information:

From:
From:

School Information: (If you do not provide care for School Aged children, skip this section)

How do the children get between school and your program? Please check all that apply

Language:

Subsidies:

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

Schedule:

Our program accepts children:*



Our program operates:*


Our program opens:*

Day
Start Time
End Time
If you accept children part time, please specify what type of part time schedule you will accommodate:

Our program provides/accepts:

Please write a short description of what you feel is special or unique about your program so that we may share it with families looking for childcare. Due to space limitations on our database, please limit your response to 35 words or less. CCR reserves the right to edit all comments.

Flexibility: Please check the boxes that apply to your program. This is above and beyond what you are listing on your schedule up above.

Rates:

Age Range
Full Time Rate
Part Time Rate
0 - 11 months
Per
Per
12 - 17 months
Per
Per
18 - 23 months
Per
Per
24 - 29 months
Per
Per
30 - 35 months
Per
Per
36 months – 5 years
Per
Per
School Day Rate
(before and after school hours)
Full Day Rate
(Holidays, school breaks, weekends, etc.)
Kindergarten
Per
Per
Grades 1 and up
Per
Per

Additional Fees: (Check all of the following that apply to your program)

Environment: (Check all of the following that apply to your program)

Meals:

Program Enhancements: (please check all that apply)

Special Needs: The Americans with Disabilities Act (ADA) requires all child care providers to make reasonable accommodation to include and support children with special needs. Please answer question 1 to best describe your experience caring for children with special needs and answer questions 2 and 3 as applicable.

Question 1: In your program, do you have experience and/or training related to caring for children with special needs?

Question 2: If you checked YES for question 1, which of the following thirteen specific accommodations can you provide?

Question 3: In addition to the specific accommodations you indicated that you can provide, which of the following apply to you and your program?

Education: (Please send documentation for Degrees or Certificates)

Accreditation: (Please send documentation)

Affiliation: (Please check all that apply)

Advocacy: Local (city and county) and state policies often affect children, families and child care providers. Your voice makes a difference!

Field Trips: Does your program take children in your care on field trips? If yes, how are the children and staff transported?

TV/Video Screen Time:

Enrichment Activity:

Technical Assistance Information

Referral Status:

For Family Child Care Providers

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 do NOT report any individual information about any specific person. Completing this information is optional.
Gender:  

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
Family Size Gross Household Yearly Income
1
2
3
4
5
6
7
8

Hud Guidelines - Updated 2012

Ethnic background:


Residing in:    

Submit