Child Care Link

 

Contact Person-Director/Provider:
First Name: Last Name:
Licensed operator/Regulated Provider's Name:
Business Name:
Physical Location:
Street Address:
City: State: VA Zip: County: Landmarks:
Mailing Address: (if different):
City: State: VA Zip:
Contact Information: 
Primary Phone: (ex. xxx-xxx-xxxx) Secondary Phone: Fax:
Email:
Website:
Type of Care: (please check only one)
Child Care Centers (group care for children with a variety fo ages) Preschool Program only (a part day program for preschoolers)
Family Child Care Provider (private home care that is not the child's home)

Head Start Program
School Age Program only (group care for children 5 years and up) After School Mentoring/Tutoring Program
Camp Program (group program for children usually with an outdoor component and generally operates only in the summer)
Parent's Day Out (scheduled drop in care program)
Type of Regulation: (check only one)
Licensed/Regulated Center Based Program Licensed Home Based Program
Voluntarily Registered Home Based Program DSS locally approved home or individual (Certified-County of City Dept. of Social Services)
Religous Exempt Center Certified Public School Preschool
Unregulated home or individual State Exempt Instructional/Recreational
American Camping Association Other:
License Expiration Date: Program accepts children from age: to
Capacity:
Age Group
Age Range
Licensed Capacity
Actual Capacity

Licensed Capacity
Desired Capacity
Total Vacancies
   
   
   
   
Schools and Transportaion: School District:
1.Is your program on public school transportation route? YES NO

If yes which schools provide transportation to your program?

2. Does your program provide transportation? YES NO

If yes which schools does your program provide transportation to?

3. Is your program walking distance from school? YES NO

4. Is your program on public bus line? YES NO

Head Start Funding: YES NO State Pre-K funding: YES NO
Languages spoken: English Spanish Asian Sign Other (please list)
Hours of Operation:
Days of Week
Start Time (hour)
End Time (hour)

Accepts Children: Duration:
Extra Care Services: ??? Enrollment Requirements:???
RATES/FEES/OTHER: (Please put N/A if not applicable-for example, if no hourly rate)
Age Group
Age Range
Full Time Weekly Rates
Daily Rates
Hourly Rates
Before & After School
After School
Before School

Infant 1
Infant 2
Toddler
Preschool 1
Preschool 2
School-Age 1
School-Age 2

Additional Fees:???

Meals: ???
Environment: ???
Parent Provides (which meals?)???

Philosophy: ???

Other: (please list)

Financial Assistance: ???

Other: (please list)

Policies: ??? Safety: ???
Special Needs: Yes No Please check the choices below that apply.

Adaptive Special Equipment

 ADD/ADHD Allergies Cognitive   
Asthma/Respiratory Autism/Aspergers CP/Neuralgic/Seizure Disorders      
Developmental Delay Diabetes Dispense Medication Down Syndrome   
Experience/Training/Facility /Desire Medical ODD Physical   
Post Traumatic Stress Disorder PT/OT Social/Emotional      
Learning Disabled Resources Space for therapy         
Training:???
Experience:???
Education: ???

Accreditation: Other:

Affiliation: ???
Advocacy: ??? Curriculum: ??? Other:
Please include my childcare information for:
Web Referrals: Yes No
Referrals to Parents: Yes No
FYI Newsletter mailings: Yes No

Do Not include my information in Parent Referrals

I certify that the information on this form is true and correct, and that I am legally operating within the laws and child care regulations of the Commonweatlh of Virginia. I agree to enroll children without regard to race, color, religion, sex, age, veteran status, national origin, disability or political affiliation. I agree to notify Child Care Link Child Care Resource and Referral within 30 days of any changes in the child care facility's phone number, address, regulation or certification status.

By typing my name in the area provided for my signature I agree with the above statement:

Signature: Date:

 
???For multiple selections hold shift key down while selecting your choices???