Child Care Provider Information Update Form


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

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 or you to the school?
Do you provide transportation to & from home?
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 (a predetermined relationship between a provider and a family for occasional use)
Temporary Emergency Care (short-term temporary care, usually lasting more than one day)
Rotating Schedule (care during shifts and/or days that change)
Before School Care
After School Care
Respite Care (respite care is temporary/short term care of a child with special needs)

How much do you charge for full time care?(please indicate if daily, 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 (part-time is less than 25 hours per week)?(please indicate if daily, weekly, monthly, etc.)
0-11 months
1 year
2 years
3 years
4 years
5 years(kindergarten)
6 years & up
How many children do you currently have enrolled in each of the following age groups?
0-11 months
1 year
2 years
3 years
4 years
5 years(kindergarten)
6 years & up
What is your capacity by age group? How many children can you care for in each of the following age groups?
0-11 months
1 year
2 years
3 years
4 years
5 years(kindergarten)
6 years & up
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

Policies(select all that apply)

You offer a multiple child discount
You accept payments from subsidy programs (4-C or other)?
You offer a daily rate if a child is only scheduled to come 1 or 2 days per week.
You offer reduced rates based on the parents income.

Do you or any of your staff have? (check all that apply)

RN/LPN
CNA
CDA
Commonwealth Child Care Credential
Director's Credential

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

Would you like to be part of the 4-C listserve that allows 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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