Family Child Care Home Provider Update Form

Family Child Care Provider Name

Business Name

Street Address

Zip Code

Major Cross Streets

(Example: 24th Street and F Street)

Home Phone Number

Phone Number Parents Should Call

Fax Number

Email

(Example: kisilva@kern.org)

Current Openings

Please update your openings every 3 weeks

Number of vacancies

Please enter a number from 0 to 5000.

Date vacancy is expected

How many children are you licensed for?

Please enter a number from 0 to 5000.

What ages do you care for?

From

Please enter a number from 0 to 100.

To

Please enter a number from 0 to 100.

Do you prefer to care for a narrower age group?

Yes
No

If "yes", what ages?

From

Please enter a number from 0 to 100.

To

Please enter a number from 0 to 100.

Check all the days that you provide care

Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

What time do you provide care? Start time

What time do you provide care? End time

Do you operate

All year long
During the school year ONLY
Summer ONLY

Do you provide Before-and-After-School care?

Yes
No

If "yes", what ages?

Name(s) of Elementary School(s) near business

Is there a school bus stop near your facility?

Yes
No

If "yes", to which schools?

Do provide transportation?

Yes
No

If "yes", to which schools?

Do provide transportation to/from child's home?

Yes
No

What do you charge?

(This information is for CCCC internal purposes only and will not be given out to parents)

Infant/Toddler (Age 0-23 months)

Full Time $

Per

Part Time $

Per

Preschooler (Age 2-5 years)

Full Time $

Per

Part Time $

Per

Kindergartener and up

Full Time $

Per

Part Time $

Per

Can you, or persons on your staff, converse in a language other than English?

Yes
No

If yes, please list languages

Are you a part of the Community Connection for Child Care Food Program (CCFP)?

Yes
No

If "no", would you like a CCFP representative to contact you about enrolling?

Yes
No

Do you or your staff have any experience in providing care for children with special needs?

Yes
No

If "yes", what training, experience and/or accomodations does you and your staff have?

Would you like to share any other information about your family child care business to help parents learn more about your program?

Based on your knowledge of CCCC services, please grade the quality of services you received from CCCC.

As a result of your experience with the Resource & Referral/Resource Library, what service-related improvements can you suggest?

Thank you for taking the time to complete this form. Please click the Submit Form button to send us your information.

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Where are we located?

Current Openings

What ages do you care for?

What do you charge?