DATA FORM FOR CHILD CARE PROVIDERS


Thank you for your assistance in supplying this valuable information. Please feel free to contact the Information & Referral Department at 502-636-1358 or email 4cinfo@bellsouth.net if you have any questions.

Contact Information

Business Name
Contact Person
Address
City
State
Zip Code
County
Telephone
Secondary Phone
Fax #
E-mail Address
Website
Do you wish to receive referrals from 4-C?
yes no

Do you want your information to be available to parents who search for child care on the 4-C website?

yes no

Type of Program (select one)

Licensed family child care home
Certified family child care home
Child care center
Preschool
School age program
Registered Ministry
Parents Day Out
Head Start

Capacity and Vacancies

Total licensed/certified capacity
Total current enrollment
Total vacancies
Total number of Employees
What ages do you serve?
From To
Which school district are you in?
Which schools provide transportation to your program?
Are you within walking distance of any schools?
yes no

Which schools do you provide transportation to?

Do you provide transportation to & from home?
yes no

Do you receive State Pre-K funding?

yes no

Do you receive Head Start funding?

yes no

What languages are spoken by you or a staff person in your program?

English American Sign Language Spanish
Vietnamese French Russian
Chinese Bosnian German
Italian Other

Hours of Operation (please indicate opening & closing times)

Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
What is your yearly schedule?
Full year School year only Summer only

What is your weekly schedule?

Full time Part time Both

Do you offer any of the following options?(select all that apply)

Drop-in Care Temporary Emergency Care Rotating Schedule
Before School Care After School Care Respite Care

How much do you charge for full time care?(please indicate if weekly, monthly, etc.)

0-11 months
1 year
2 years
3 years
4 years
5 years(kindergarten)
6 years & up
How much do you charge for part time care?(please indicate if weekly, monthly, etc.)
0-11 months
1 year
2 years
3 years
4 years
5 years(kindergarten)
6 years & up
Do you charge a registration fee?
yes
no

If so, how much?

Do you charge an additional fee for any of the following? (select all that apply)
Supply Waiting List Meal/Snack Other

Is your program non-profit?

yes no


Environment(select all that apply)

No pets Smoke free
Fenced Yard Wheelchair Accessible
On the TARC line Swimming pool
Outside Play area (not fenced)
Indoor pets what kind
Outdoor pets what kind

Meals(select all that apply)

Breakfast AM snack Lunch
PM snack Dinner Infant food
Infant formula Participates in USDA food program (4C or self sponsoring)
Parents provide Meals/Snacks Special Diet

Policies(select all that apply)

Multiple child discount Accept payments from subsidy programs (4-C or other)?
Do you offer part week rates for infants & toddlers? Do you offer part week rates for other ages?

Special Skills

RN/LPN
CNA

Safety(select all that apply)

Video Monitoring system Parental Internet Viewing system
Keypad/Keycard access Other

Which of the following Special Needs have you had experience with?(select all that apply)

Emotional/Behavioral (ADD, ADHD, etc.)
Speech/Hearing
Physical/Mobility (wheelchairs, braces, etc.)
Medical conditions (allergies, feeding tube, apnea monitor, asthma, medications, etc.)
Developmental Delay
Autism

Education Level (check all that apply):

High School Education
Some College, Child Related
Some College, Other Emphasis
Associate Degree, Child Related
Associate Degree, Other
Bachelor's, Child Related
Bachelor's, Other
Master's, Child Related
Master's, Other

Do you or any of your staff have a CDA?

yes
no

Do you or any of your staff have a Commonwealth Child Care Credential?

yes
no

Do you or any of your staff have a Director's Credential?

yes
no

Accreditation

NAEYC NAFCC American Montessori
NAA NAC Other

Funding/Affiliation

Metro United Way funding
UAW -Ford Network member
Employer funded(which employer)

Do you have a STAR rating? If so, what level?

1 STAR
2 STAR
3 STAR
4 STAR

STAR expiration date

Do you offer any of these additional Programs?(select all that apply)
Preschool Curriculum Parents Day Out Dance
Computers Tumblebus/Gym class Karate
Head Start Pediatric Medical facility Other

Center Setting (Type I programs only)

Non-residential
Faith-based
Workplace-based
School/University-based

Do you currently care for any children of:

UAW-Ford employees
Active Duty Army
Louisville Metro Government employees

Are you open Oaks and/or Derby Day?


37. Would you like to be part of the 4-C pilot program that will allow you to receive email updates from 4-C on one or more of the following topics: advocacy, training, licensing changes, special events or offers?

yes
no


If yes, please provide us with your email address

Comments


What type of update did you just complete?
New provider (you have just become licensed or certified)
Full update (you answered every question on this form that applies to you)
Partial update (you only changed 1 or 2 items such as rates or hours)

Thank you for supplying your information to 4-C!



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