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Child Care Centers Survey

Center Name
Director's Name
Address
City, ZIP
Phone
Secondary Phone
E-mail
Web Site
2 Major Cross-Streets by Address
Mailing Address (if different from above)
City, ZIP
Infant (0-23 mon.)
License #
Effective Date
Capacity
Preschool (2-5 yr.)
License #
Effective Date
Capacity

Toddler Option

License #
Effective Date
Capacity

School Age Option

License #
Effective Date
Capacity
School Age (Kinders & Older)
License #
Effective Date
Capacity
Maximum # of Children you will serve in your program
Ages of Children you will serve
Do you provide transportation for school age children?
Are you located on the school grounds?
List schools served
School District
Language(s) that staff speaks
Vacancies (child care openings)
Total #
Infant (0-1 year 11 months)
Preschool (2 yr. - 5 yr. 11 mon.)
School Age (6 yr. & up)
What is your type &/or source of Subsidized Child Care Funding? (check all that apply)
Subsidized

Number of child care slots in your program

Infant
Preschool
School Age
Are you willing to accept CALWORKs Payments?
Days Open for Child Care (Check all that apply)

Hours

Open
Close

Infants

Full-Time Cost
Per Week
Part-Time Cost
Per Week
Comments

Toddlers

Full-Time Cost
Per Week
Part-Time Cost
Per Week
Comments

Preschool

Full-Time Cost
Per Week
Part-Time Cost
Per Week
Comments

School Age

Full-Time Cost
Per Week
Part-Time Cost
Per Week
Comments

Kindergarteners

Full-Time Cost
Per Week
Part-Time Cost
Per Week
Comments
Do you offer a Sibling Discount?
Registration fee
$
Transportation fee
$
Materials fee
$
Type of Schedule (Check all that apply)
Check all that Apply to your Child Care Center
Meals Served
Program
Philosophy
Education

Special Needs

Experience
Education
Specific Needs
Other
Religious Affiliation
What Religion?
Accreditation
Profit
Affiliation
Do you wish to be referred to parents?
If you answered No please explain why
Provider Notes
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