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?
|
Yes
No
|
|
Do
you offer multiple sessions? (i.e., am and pm preschool)
|
| |
School
Age Care:
|
Provide
care:
|
|
|
|
|
Before
School
|
|
|
After
School
|
|
|
Both
Before & After School
|
|
|
Before/After
Half-Day Kindergarten Care
|
|
|
Days
off School (vacations, holidays, snow, in-service)
|
|
|
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?
|
| |
|
|
|
|
Employee
Information:
|
|
|
Total
number of Employees
|
Highest
Educational level of Employees: Of the total, indicate how
many Employees have a...
|
|
|
|
|
|
|
|
|
|
|
|
|
Professional
Trainings: Enter the number of employees trained in the following...
|
|
|
|
|
|
|
|
|
|
| |
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 Child Care Connection.
|
Comments:
|
|
Program
Director's Name:
|
|
| |
|
|
|
|
Click
on the button below to Submit your form to:
YWCA
Child Care Resource & Referral
1018 Jefferson Avenue
Toledo, OH 43604
|
YWCA
Child Care Resource & Referral will not share or sell your
personal information.
See our Privacy Policy page
for additional information.
|
