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Child Care Resource & Referral — Provider Registration/Update Form

Fill out the following form to register your program with our Child Care Recourse & Referral. If you’re already registered with us, you may use this form to update your information. As an update only enter in information that is new

* First Name:

* Last Name:

* License Number:

Expected Date of License:

If you do not currently have a license, are you licensed exempt:
Yes No

Business Name:

* Address:

Address Line 2:

* City: * State:

* Zip Code: *County:

Closest Intersection

Licensed Capacity

Desired Capacity

Vacancies

* Phone (with Area Code)

Fax

* Email Website

* Star Level
1 Star 1 Star + 2 Star
3 Star NAEYC NAFCC

* Type of Care
Child Care Center
Family Child Care Home
School-Age Program
Preschool
Camp
Drop-in Facility
First Start
Head Start
Nanny
Other(if other, please explain):

* Accepted ages range: FROM
years months weeks TO
years months weeks

Type of Schedule:
Full Time
Part Time
Both Full / Part Time
Drop In
Temp/Emergency
Before School
After School
Rotating
24-Hour
Open Holidays

Schedule Duration: Full Year School Year Summer Only

Hours and Days of the Week the Program Is Open:
Monday: Yes No
TO
Tuesday: Yes No
TO
Wednesday: Yes No
TO
Thursday: Yes No
TO
Friday: Yes No
TO
Saturday: Yes No
TO
Sunday: Yes No
TO

If you serve multiple shift times within a specific day please state the day and time below:

Is transportation provided?
Yes No

If yes, please select the following transportation services you provide:
Walking Distance to School
Near Public Transportation
Transportation to/from School
Transportation to/from Home
Close to school bus stop
Close to city bus stop

List any school districts / elementary school(s) that are within close proximity:

Are you a part of the USDA Food Program? Yes No

Environment:
Indoor Pets
No Pets
Outdoor Pets
Smoke Free
Wheel Chair Accessible
Preschool Curriculum

Special Needs
ADD / ADHD
Allergies
Apnea (Infant) Monitor
Asthma
Autism
Diabetes
Emotional / Behavioral Disabilities
Mentally Disabled / Learning Disabled
Mentally Retarded / Learning Disabled
Physical Disabilities
Seizures
Sensory impaired

Please list your full-time fees according to age group on a weekly basis.

Please list your part-time fees according to age group on a weekly basis(if applicable).

Please check all forms of financial assistance that you offer or accept.
DHS Subsidy
Sliding Scale
Indian Contract
SSI / Special Needs

Check all that apply towards staff education and degrees.
Administrator's Credential
Associates-Child Related
Associates-Non Child Related
Bachelors-Child Related
Bachelors-Non Child Related
CDA/CCP Credential
CDA/CCP Currently Enrolled
Certificate of Mastery
Masters & Up – Child Related
Masters& Up–Non Child Related

Is there anything else about your program that you would like us to know? (Other languages spoken, special skills, etc).

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

Southeastern Child Care Resource & Referral Agency - 1-888-320-5205