4c Child Care Provider Data Update

Provider Name:
Business Name:
Program Director :
Mailing Address:
City:
Zip:
Major Cross Streets:
Phone Number:
Fax Number:
E-Mail Address:
Web Address:
License Number:
Expiration Date:
License Capacity:
Accepts Children Ages:	to
	* To select multiple choice on a drop down click on the shift key while selecting each selection.
Schedule	Part-time Full-time Drop-in Holiday care Temporary/emergency
Type of Care offered	Choose all that Apply: Before/After School care Summer school-age care Licensed exempt school-age Drop-in care
Number of total Vacancies:
As of (Date):
Days/Hours open:
School District
Nearest Elementary School
Walking Distance to School?	Yes No
Do you provide transportation?	Yes No
Is there public transportation near you?	Yes No
Infant Age Group:
Desired Capacity:
Licenced Capacity:
Cost of Care:
Full-time:
Part-time:
Other:
Toddler Age Group:
Desired Capacity:
Licensed Capacity:
Cost of Care:
Full-time:
Part-time:
Other:
Preschool Age Group:
Desired Capacity:
Licenced Capacity:
Cost of Care:
Full-time:
Part-time:
Other:
School-Age Care:
Desired Capacity:
Licenced Capacity:
Cost of Care:
Full-time:
Part-time:
Other:
Additional Fees:
Activity Fee	Yes No
Registration Fee	Yes No
Environment	Choose all that Apply: Smoke-free Air Conditioning Fenced Yard No Pets
Meals	Choose all that Apply: Child Care Food Program Breakfast AM Snack Lunch PM Snack Special Diet Dinner None (BYO)
Do you accept financial assistance?	Yes No
Do you offer a discount for families with more than one child in child care?	Yes No
Special Needs Services Provided (Example: Asthma, ADD/ADHD):
4C Trainings	Choose all that Apply: Basic Advanced Administrative Infant A,B, or C Mini Mentor Special Needs
Other trainings	Choose all that Apply: Medical Training CPR/First Aid/Blood Borne Pathogens MSU Extension
How many years have you been licensed to provide child care?	Less than 2 years 2-5 years More than 5 years
Highest Level of Education (Family/Group Home Staff):	High School Diploma/GED VO/Tech Some College ECE/ZA Associates Bachelors Masters
Highest Level of Education (Center Staff):	Director = License Minimum Director = BA/MA Head Teacher = 18 yrs. High School Diploma/GED Head Teacher = AA or CDA Head Teacher = BA/MA
How many staff are employed at your center?
Full-time:
Part-time: