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I am a Provider

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?:
 
Yes
No
Are you located on the school grounds?:
 
Yes
No
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):
 
None, Parent Fees Only
Head Start Contract
CDE Contract
Other Public Contract
General Child Care
Federal Block Grant
State Pre-School
Subsidized:
Adult Education
Network
School District
SAPID
Alternative Payment
Migrant
Latch Key
Campus
City
County
United Way
Other
Number of child care slots in your program
Infant:
Preschool:
School Age:
Are you willing to accept CALWORKs Payments?:
 
Yes
No
Days Open for Child Care (Check all that apply):
 
Mon
Tues
Wed
Thurs
Fri
Sat
Sun
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?:
 
Yes
No
Registration fee: $ 
Transportation fee: $ 
Materials fee: $ 
Type of Schedule (Check all that apply):
 
Full-Time
Part-Time
Drop In
Rotating
Before School
After School
Open Holidays
Temp. Emergency
Sick Care
Full Year
School Year Only
Summer Only
Check all that Apply to your Child Care Center
Meals Served:
Breakfast
AM Snack
Lunch
PM Snack
Dinner
Program:
Pre-School
Developmentally Appropriate Activities
Philosophy:
Free Play
Academic
Recreation
Montessori
High Scope
Pre-Kindergarten
Waldorf
Education:
Early Childhood Education
Education in Related Field
Special Needs
Experience:
Yes
No
Education:
Yes
No
Specific Needs:
Behavior Problems
Developmental Delay
Physical Disability
Health Impairment
Visually Impaired
Deaf-Hard of Hearing
Other:
Religious Affiliation:
Yes
No
What Religion?:
Accreditation:
NAEYC
Profit:
Not for Profit
For Profit
Affiliation:
School District
College
Park & Recreation
Adult Education
Franchise
Do you wish to be referred to parents?:
 
Yes
No
If you answered No please explain why:
 
Provider Notes:
 
 
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