Director Name:  

Business Name :    
SSN# or Federal ID # :    
License # :  

Address : 
     Address:         Unit #:    
     City:          
     County:      
     Zip:          

Mailing Address (if Different):  

Contact Phone Number:     or 

Fax Number:  

eMail:  

Website:  

Licensing Information

Type of care that you provide (Check all that apply)

  Child Care Center
  Family Child Care Home
  Group Child Care Home
  Pre-school Program
  School Age Program
  Faith-based Program
  Head Start
  Private School
  Public School 
  Camp

Department of Social Services (DSS) Status (Check all that apply)

Licensing Capacity   
Desired Capacity   
Total Vacancies    as of (date)   
Ages served   
When did your program open? 

Do you you wish to be given referrals?
  Yes 
  No

School Transportation Information
Please list any schools for which transportation is provided

       To School    From School 
       To School    From School 
       To School    From School

Center Funding 
Sources of Funding (check all that apply)

  Head Start
  State 4K
  ABC Grant Recipient
  First Steps Grant Recipient
  Other 

Operational Information 
Services for Families (check all that apply)

Preschool Programs 
  5 Mornings a week
  2-3 Mornings a week
  Mothers Morning Out

After School Programs 
  5 afternoons a week
  5 Mornings a week
  4 or fewer afternoons a week
  4 or fewer mornings a week

Financial Services for Families
  Accept ABC Voucher
  Sliding fee Scale
  Multi-Child Discount
  Employer Discounts
  Scholarships

Languages Spoken and / or Taught (check all that apply)

  English
  Spanish
  French
  Other 

Hours of Operation

  Monday -------- Open at    Close at   
  Tuesday ------- Open at    Close at   
  Wednesday -- Open at    Close at   
  Thursday ------ Open at    Close at   
  Friday -----------Open at    Close at   
  Saturday ------ Open at    Close at   
  Sunday -------- Open at    Close at 

Do you accept children
  Full-time 
  Part-time 
  Both

Program Duration
  Full Year 
  School Year 
  Summer Only

Do you provide for mildly ill children?
  Yes 
       Even if not enrolled?
         Yes 
         No 
  No

Do you offer care for special schedules? (check all that apply)
  Drop-Ins 
  24 hour care 
  Weekends 
  Before School
  After School
  School Vacations / Holidays 
  Rotating Schedules 
  Shift Work 
  Temporary or Emergency Care

Additional Fees

Registration Fee   
Late Pick Up Fee   
Late Payment Fee   
Other Fee(s)   

Attributes (Check all that apply)

  I am interested in learning about accreditation through the National Association for the education of Young Children (NAEYC)

  I am interested in learning about accreditation through the National Association for Family Child Care (NAFCC)

Please make any other comments that you would like parents to know about your program
      
      
      
      

Professional Staff Development

Director Information

Director Highest Level of Education Completed:
  Less than High School Diploma/GED 
  High School Diploma or GED 
  Associate Degree; Child Related 
  Associate Degree; Non Related 
  Bachelors Degree; Child Related 
  Bachelors Degree; Non Related 
  Masters Degree; Child Related 
  Masters Degree; Non Related 
  Ph. D Early Childhood or related field
  Some Child-related Course Work

Director Training (check all that apply)
  15 Hours of DSS Credit 
  Family Childcare Home ABC Child Care Credential
  Childcare Center ABC Child Care Credential 
  Family Day Care Rating Scale 
  Infant/Toddler Environmental Rating Scale 
  Early Childhood Environmental Rating Scale 
  Child Development Association 
  SC Child Care Credential (ECD 101) 

Teacher Information

Number of Teachers and Assistants 

Important Information -
        for Statistical Purposes Only

Benefits Offered to Employees (check all that apply) 
  Health Insurance 
  Dental Insurance 
  Life Insurance 
  Child Care Discount 
  Tuition Reimbursement 
  Paid Holidays 
  Paid Sick Leave 
  Paid Vacation 
  Retirement Account 
  Other 

Number of employees who are Spanish/Hispanic/Latino
  Mexican/Mexican-American/Chicano
  Puerto Rican
  Cuban
  Other 

Number of employees whose race is
  White 
  Black 
  American or Alaska Native. Tribe   
  Asian Indian 
  Native Hawaiian 
  Chinese 
  Filipino 
  Japanese 
  Vietnamese 
  Other Asian:   
  Guamanian or Chamarro 
  Samoan 
  Other Pacific Islander:   
  Other   

English Language Ability
  Number employees who speak other than English at home. 
        Language 

How well do these employees speak English (check all that apply)
  Very Well 
  Well 
  Not Well 
  Not at All

  I accept these conditions; I understand that Child Care Resource & Referral (CCR&R) only makes referrals, not recommedations, to families. I agree to assist CCR&R in maintaining up-to-date information on the Child Care availibility by reporting changes in my facility when they occur. I give CCR&R permission to release the information in this form to parents seeking Child Care services.
My Name (electronic signature) is 

I wish to be contacted for updates by (check all that apply)
  Telephone 
  Email 
  Fax 
  Mail

If you have any questions, please contact CCR&R at (843) 747-9900 or 1 (877) 227-3454 toll free or email care4kids@tuw.org.