CCC Program Information Form


Part of a state-wide network of referral agencies, Child Care Connection serves Mahoning, Medina, Portage,

Summit, Stark, and Trumbull Counties in Ohio.

Program Information Form



Business Name:
Fax Number:
Mailing Address:
Contact Person:
Contact Title:
Do you have a contract with your County Department of Job & Family Services? Yes   No
What are the ages of the children in your care? From: To:
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:
Sat/Sunday... Hours From: To:

Capacity:  (enter number for each)
Total Program Capacity Total Program Vacancies
Infant Capacity Infant Vacancies
Toddler Capacity Toddler Vacancies
Preschool Capacity Preschool Vacancies
School Age Capacity School Age Vacancies
Do you accept infants part-time? Yes  No
If yes, what are the minimum number of days?
Do you offer multiple sessions? (i.e., am and pm preschool) Yes  No
Provide care for:  

Before School

After School

Both Before and After School

B/A Half-Day Kindergarten Care

Summer Care

Days off School (vacations, holidays, snow, in-service)

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?
Total number of employees
# of Full time employees
# of Part time employees
Highest Educational level of Employees:  Of the total, indicate how many employees have a...
High School Diploma/GED 4 year degree
Some college/No degree 2 year degree
CDA Completed Masters degree
CDA in progress  
Professional Trainings: Enter the number of employees trained in the following...
First Aid CPR Child Abuse Recognition
Nutrition Early Childhood Communicable Disease
PROGRAM INFORMATION  (please check all that apply to your Program offerings)
Yes  No
Transportation to/from school
Transportation to/from child's home
Schedules/Special Services:
Full time only
Part time only
Both PT and FT
Full Year Care
Summer Care
School Year Care
Drop In Care
Sick Care
24 Hour Care
Extended Hours Care
Respite Care
MR/DD Care
Temporary/emergency/back-up Care
Non-smoking Outdoor Play Area Fenced Yard
Has a pool Gym Near Public Transportation
Wheelchair Accessible Has pets indoors (list pets you have)
Meals Provided:
Breakfast Morning Snack Lunch Afternoon Snack
Supper 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
System Independent Non-Profit Public School
College Church Public NSACA
NAEYC Accredited ACA Accredited Camp ODJFS Camp Registry
Program Philosophy: (Please check categories that apply to your program.)
Montessori Mixed Age Developmentally Appropriate Practicies
Parent Co-Op Faith Based Curriculum Intergenerational (Children & Adults)
Reggio Emilia    
Special Needs: (Check the type of care your program provides.)
Speech/Hearing Emotional/Behavioral Physical-Mobility
Medical Conditions MRDD None
PROGRAM FEES  (Please indicate $ Amounts)





Preschool Age
School-age: B/A school
School-age: Summer
Check all types of Financial Assistance your program offers:
County Voucher

Sliding Fee Scale

Multi-child discount


Employee discount

Is there a Registration Fee? Yes    No
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 referrals and complaints established by Child Care Connection.

Program Director's Name


Click on the button below to Submit your form to:
Child Care Connection
474 Grant Street
Akron, Ohio  44311

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