Provider Information Form

Name*

First

Last

Business/Facility Name*

License/Provider Number (PV#)*

Address*

Zip*

Do you have a different mailing address?

Yes

City*

County*

State*

Address (mailing)

Zip (mailing)

City (mailing)

County (mailing)

State (mailing)

Primary Phone Number*

Area Code

Phone Number

Email Address

Fax Phone Number

Area Code

Phone Number

Website

Child Ages Served

Years

Months

Weeks

Youngest Age

Oldest Age

Capacity/Enrollment

Desired Capacity

Current Enfollment

Infant (0-23 months)

Toddler (2 years old)

Preschool (3-5 years)

School Age (6 years old and older)

Full-Time Vacancies

Full-Time Vacancy

Date Vacancy Begins

Infant (0-23 months)

Toddler (2 years old)

Preschool (3-5 years)

School Age (6 years old and older)

Part-Time Vacancies

Part-Time Vacancy

Date Vacancy Begins

Infant (0-23 months)

Toddler (2 years old)

Preschool (3-5 years)

School Age (6 years old and older)

Do you maintain a waiting list when you do not have vacancies?*

Yes

Please list public schools served:

Choose all that apply.

Transportation provided for children to/from the family's home.

Transportation provided for children to and from activities.

Child care facility is located near public transportation.

Transportation provided for children to and from school.

Transportation provided for children to and from bus stop.

Child care facility is located within walking distance to school.

Please list hours of operation.*

If you offer extended hours, please specify.

Please list the Holidays the your facility is opened.

Is your facility opened...*

Full year

School year only

Summer only

Do you accept....*

Full-time children only

Part-time children only

Both full-time and part-time children

Do you participate in the Best Beginnings Child Care Scholarship?

Yes

Do you participate in the STARS to Quality program?

Yes

What STARS to Quality level is your child care facility on?

Please check all that apply.

Seperate sick area for children while waiting for parent to pick up

Charges for absent days

Closed for vacations and sick days (closes facility when on vacation or sick)

Uses substitutes when absent (keeps facility open by using substitutes)

Charges for holidays when facility is closed

Please select the numbers of years of education for the Director of your child care facility.

Please list the educational background for the Director of your child care facility.

Are you a current member of the following professional organizations?

MTAEYC

MTCCA

In your own words, what do you want parents to know about your facility. (This is the exact text that will be available to parents on on child care referrals.)

I grant perrmission for my child care facility to be added to both the referral database and online referral database.*

I agree

I understand the preferred method of contact is email. If you entered a email address above, the email will be used to communicate with you.*

I agree

The following information will appear on the child care facility profile: First Name, Business Name, Address, City/State,Zip, Facility Type, Phone Number, Hours/Days, Ages Served, Map to Street, Rates and Full/Part Time.*

I agree

I hereby affirm that the statements in the Provider Information Form are accurate, complete and true to the best of my knowledge.*

I agree

I agree to provide additional documentation concerning the Provider Information Form to the regional CCR&R agency at their request.*

I agree

I understand that it is my responsibility to keep my provider information updated with the regional CCR&R agency and to complete this form on an annual basis unless otherwise requested.*

I agree

Please enter your full name as signature on this form.*

Please enter the letters/numbers:

The Nurturing Center

Strengthening Families – Sustaining Communities

Provider Information Form