CASY Resource & Referral Provider Update Form

 
Thank you for taking time to provide us with information regarding your child care business. This information will assist us in providing families in need of child care with accurate referrals to your child care and/or in understanding the needs of our communities related to child care. Please note: Referrals will only be made if you have indicated that you would like to receive referrals by checking the box below. Only Licensed Child Care Centers, Licensed Family Child Care Homes, Unlicensed Registered Ministries, and those meeting referral requirements are eligible for referrals. For more information on referrals please call our office. All information provided to our office is confidential and will only be shared with your consent.

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First and Last Name of enrollment contact person:
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Business Name:
How do you prefer to udate your child care program information in the future?
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Type of Care:
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Name as listed on License/Registration:
State License Number/Facility ID:
State License/Facility ID Expiration Date:
Please provide the site information:
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Please provide contact information:
Please provide the mailing address ONLY if it is different from the location address above.
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In which language do you prefer communication (letters,documents, etc.)?
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I would like to receive referrals through the CASY office:
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I would like to be included in online referral searches that families complete.
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Total Licensed/Registered Capacity:
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Total Desired Capacity:
Please provide your current openings for each age group:
Please provide your current enrollment for each age group:
Please specify the ages served in your site:
monthsyears
Youngest Age
Oldest Age
Have there been any changes since your last update with the CASY Referral Specialist? ****Please note that many options have recently changed below****
Hours of Care
OpenClosed
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Accepts Children:
Duration:
Extra Services:
Does your program accept either type of funding?
How many families is your program currently caring for that are involved in the military?
Schools Served:
School District:
Transportation, if available:
Does child care staff (who care for the children) speak any of the following languages fluently:
Environmental features of your child care program (select all that apply):
Please list what meals are served in your facility?
Are you currently participating in the CACFP (Child & Adult Care Food Program)?
Select any philosophy that is currently used within your program:
Select any Special Need(s) for which staff within your program has training or education:
How many staff members do you have for this site? (part or full time)
Select any of the following financial assistance options your program offers to families:
Which option best describes the physical setting of your child care program:
Does your child care program provide care ONLY for any of the following groups?
Please enter the amount charged for Infants: Age Range 0-12 months:
Please enter the amount charged for Toddlers: Age Range 13-23 months:
Please enter the amount charged for Toddlers: Age Range 24-35 months:
Please enter the amount charged for Preschoolers: Age Range 3-4 years:
Please enter the amount charged for Preschoolers: Age Range 5 years:
Please enter the amount charged for School Age: Kindergarten:
Please enter the amount charged for School Age: Before/After only:
Please enter the amount charged for School Age: Summer Care:
Additional Fees:
Additional comments, services, or resources?
Thank you for your time!