Child Care Program Information (New Intake)

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Contact Information:












Mailing Address (if different from Location Address):










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Off-Site Disaster Contact:

























Days Child Care is provided
Start Time End Time
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Rate Information

Private Pay Clients
Weekly Part Time Weekly Full Time
Infant (0-12 months)
Toddler (13-23 months)
Toddler 2 (24-35 months)
Pre-School (36-47 months)
Pre-School 2 (48-60 months)
School Age (61+ months)
DHS Subsidy Clients
Weekly Part Time Weekly Full Time
Infant (0-12 months)
Toddler (13-23 months)
Toddler 2 (24-35 months)
Pre-School (36-47 months)
Pre-School 2 (48-60 months)
School Age (61+ months)
Population Information
Desired Capacity Licensed Capacity Vacancies
Infant (0-12 months)
Toddler (13-23 months)
Toddler 2 (24-35 months)
Pre-School (36-47 months)
Pre-School 2 (48-60 months)
School Age (61+ months)
Enrollment Fees
None
Charge for 1st child
Charge for each additional child
One time fee? yes or no
Number of children on waiting list
Any supply fees?
Field Trip fees?









This section is for Family Child Care Homes Only. If you operate a center, skip to next section

Census Bureau questions:



This section for all other child care programs
Please list the number of staff members who are:
Racial Background of Staff Members




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