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Center Based Program Update - Lima
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Program Information Form
Date:
  
Business Name:
  
Address:
  
City:
  
State:
  
Zip Code:
 
County:
  
Phone Number:
  
Fax Number:
  
Email:
  
Contact Person:
  
Contact Title:
  
General Information:
 
Do you have a contract with your County Department of Job & Family Services?
From
 
What are the ages of the children in your care?
Days/Hours of Operation: (Check all that apply and fill in hours.)
Monday
 
Hours From to
Tuesday
 
Hours From to
Wednesday
 
Hours From to
Thursday
 
Hours From to
Friday
 
Hours From to
Saturday
 
Hours From to
Sunday
 
Hours From to
Capacity: (Enter number for each.)
 
 
Toddler Capacity
 
Toddler Vacancies
Preschool Capacity
 
Preschool Vacancies
Schoolage Capacity
  
Schoolage Vacancies
 
Do you accept infants part-time?
 
If yes, what are the minimum number of days?
 
School Age Care:
Provide care:
    
 
Before School
 
After School
 
Both Before & After School
 
Summer Care
   
List the Elementary School(s) your program serves?
   
   
If your program does not provide transportation, how do the children get to and from the schools listed above?
   
Program Information:
Please check all that apply to your Program offerings...
Yes No
  
Transportation
Yes No
  
Transportation to/from School
Yes No
  
Transportation to/from Child's Home
Schedules/Special Services:
Full-Time Only
 
Part-Time Only
Both Part-Time & Full-Time
  
Rotating
Full Year Care
  
Summer Care
School Year Care
  
Vacations/Holidays
Drop-In Care
  
Sick Care
24-Hour Care
  
Extended Hours Care
Respite Care
  
Temporary/Emergency/Back-Up Care
MR/DD Care
  
Environment:
Non-Smoking
  
Outdoor Play Area
Fenced-Yard
  
Has a Pool
Gym
  
Near Public Transportation
Wheelchair Accessible
  
Has Pets Indoors (list pets)
   
Meals Provided:
Breakfast
  
Morning Snack
Lunch
  
Afternoon Snack
Dinner
  
Evening Snack
Special Diet
  
Parent Provided
 
How many years has the center been in operation?
With what other programs does your program collaborate?
Head Start
  
Preschool Curriculum
Playgroup
  
Early Start
 
Other:
   
Affiliation:
System
  
Independent
Non-Profit
  
Public School
College
  
Church
Public
  
NSACA
NAEYC Accredited
  
PACA Accredited Camp
ODJFS Camp Registry
    
Step Up to Quality Rating:
1-Star
  
2-Stars
3-Stars
    
Program Philosophy: Please check categories that apply to your program...
Montessori
  
Developmentally Appropriate Practices
Mixed Age
  
Intergenerational (Children & Adults)
Parent Co-Op
  
Faith-Based Curriculum
Reggio Emilia
    
Special Needs: Check the type of care your program provides...
Speech/Hearing
  
Emotional/Behavioral
Physical-Mobility
  
Medical Conditions
MR/DD
  
None
Program Fees:
Please indicate the dollar amount:
Infants:
  
Toddlers:
  
Hourly Daily Weekly
Pre-School Age:
  
Hourly Daily Weekly
School Age B/A School:
  
Hourly Daily Weekly
School Age Summer:
  
Hourly Daily Weekly
Check all types of Financial Assistance your program offers:
County Voucher
  
Sliding-Fee Scale
Scholarship
  
Employee Discount
Multi-Child Discount
    
Yes No
  
Is there a Registration Fee?
 
If Yes, what is the Registration Fee?
   
Do you charge other fees? Please explain:
   
Yes, I have read and understand the policies and procedures for
referral and complaints established by YWCA Child Care Resource & Referral.
Comments:
Program Director's Name:
     
Click on the button below to Submit your form to:
YWCA Child Resource & Referral
616 S. Collett St., Suite 203
Lima, OH 45805 
 
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