Family Child Care Information Form

Family Child Care 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.

Date:
Name:
Business Name:
Email:
Address:
City/State/Zip:
Phone:
Fax Number:
County:
Mailing Address (include City & Zip):
CHECK ALL THAT APPLY REGARDING YOUR SERVICES. YOU MAY CHECK MORE THAN ONE ITEM.
Are You Certified? Yes No If yes, what county?
What are the ages of the children in your care? From: To:

SCHEDULES:
Regular Full-time care Part-time care Rotating schedules	Yearly Full Year care Vacations/Holidays Summer care School Year	Special Services Drop-in care 24 hour care Sick care Respite care Flexible Hours Temporary/emergency/backup care

SCHOOL-AGE CARE:
Will you provide before and after school care?		Yes No
If yes, what elementary school(s) are closest to you?
Do you provide transportation? Yes No
If yes, check all that apply: To/From School To/From Child's home
If you don't provide transportation, how do children get to and from school? (walk, school bus, etc.)

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:
VACANCIES: (HOW MANY VACANCIES?)

Day: Evening: Overnight:

EDUCATION: (check highest level achieved)
High School Diploma/GED		4 year degree
Some college/No degree		2 year degree
CDA Completed		Masters degree
CDA in progress

PROFESSIONAL TRAININGS: (check all that apply)
First Aid	CPR	Child Abuse Recognition
Nutrition	Early Childhood	Communicable Disease

EXPERIENCE:
How many years experience do you have in childcare? 0 - 1 year 1 - 3 year(s) 4 - 9 years 10 - 20 years Over 21 years	Do you have experience caring for children with special needs? Yes No (If yes, check all that apply.) Emotional/Behavioral Physical-Mobility MRDD Speech/Hearing Medical Conditions

FEES:
	HOURLY	DAILY	WEEKLY
Infants
Toddlers
Preschool Age
School-age: B/A school
Summer Rate
Holiday Rate

I wish to receive referrals from Child Care Connection			Yes No
Do you offer a multiple child discount?			Yes No
Do you have a partnership with HeadStart?			Yes No
Are you enrolled in the Child & Adult Food Program?			Yes No
If no, would you like information on the Child & Adult Food Program?			Yes No

Yes, I have read and understand the policies and procedures for referrals and complaints established by Child Care Connection.


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

Info Line, Inc. ... Bringing people and services together since 1975

474 Grant Street • Akron OH 44311 • 330-762-5627 • 330-253-1137