Please fill out the form below to provide correct contact information, hours of operation, current rates and MORE! This will help with correct information for the state referral line. If you have questions please email

tulsaccrr@okschoolreadiness.org

Para la versión en español, haga clic aquí.

Contact Information

Contact Person's First Name

Contact Person's Last Name

Name of Facility

K8#

Current Address

City

State

Zip

Mailing Address (if different)

Primary phone

Secondary phone

E-mail address

Website

Transportation

Do you transport children?

QRIS

What is your star level as set by DHS?

Message to Families: (a short program overview)

Schedule

What days and times are you open? Put NA for the days you are not open.

	Start Time	End Time
Mon.
Tue.
Wed.
Thu.
Fri.
Sat.
Sun.

Year Schedule

Ages, Rates, & Openings

Rates

Please enter the full-time weekly rate (or range of rates, if it varies):

	FT Weekly Rate
Infant (0 - 11 months)
Toddler (12 - 23 months)
Twos (2 years)
Preschool (3 years)
Pre-K (4 years)
Kindergarten (5 years)
School-Age (6 years & older)

Openings

Please enter the number of openings you currently have by age group:

	Openings
Infant (0 - 11 months)
Toddler (12 - 23 months)
Twos (2 years)
Preschool (3 years)
Pre-K (4 years)
Kindergarten (5 years)
School-Age (6 years & older)

Private Pay

Please enter the amount of non-subsidized children enrolled in the program:

	Private Pay Enrolled
Infant (0 - 11 months)
Toddler (12 - 23 months)
Twos (2 years)
Preschool (3 years)
Pre-K (4 years)
Kindergarten (5 years)
School-Age (6 years & older)

Accepted Age Range:

Youngest

Oldest

Do you charge a registration fee?

YesNo

Do you charge a supply fee?

YesNo

List Tribe(s):

Special Needs

Can you accept the following special needs (check all that apply)?

Inclusion:

BehavioralDevelopmentalMedicalPhysical

Customized Data

Does this program receive tribal funds (other than subsidy)? If yes - list tribe(s) below:

Are you or any of your employees fluent in another language? Please provide name of speaker & language(s) spoken:

If he/she is Spanish speaking, would he/she like to attend trainings in Spanish?

YesNoMaybe

How many direct care staff do you typically employ?

Emergency Off-Site Disaster Contact Information

Please provide a name and phone number of an alternate person we can contact during a disaster if phone lines/cell towers are down.

Name & Relationship

Phone

Contact Information