Annual Family Child Care Provider Questionnaire Survey

1. Family Provider Questionnaire - Contact information

Instructions: Please answer the following questions regarding your family child care home. If there is information you do not wish to share or you feel does not apply to you, please indicate with a "NR" (not relevant) in the space provided. If you have any questions or concerns about the questionnaire, feel free to call the LOCATE staff at 410.659.7701 x230. You can also contact us via email, fax, or mail at Maryland Family Network, 1001 Eastern Ave., 2nd Flr., Baltimore, Maryland 21202, fax 410.385.0561, providersupport@marylandfamilynetwork.org.

1. Date questionnaire completed:

	MM		DD		YYYY
Enter:	Date questionnaire completed: Enter: Month	/	Day	/	Year

2. Provider license number:

Provider license number:

3. First Name:

First Name:

4. Middle Initial:

Middle Initial:

5. Last Name:

Last Name:

6. Site Address:

Site Address:

7. Community/Development:

Community/Development:

8. City:

City:

9. Zip code:

Zip code:

10. Mailing address (if different from site address):

Mailing address (if different from site address): Street Address:
City:
Zip Code:

11. What county do you live in?

What county do you live in? Anne Arundel

Allegany

Baltimore City

Baltimore County

Calvert

Caroline

Carroll

Cecil

Charles

Dorchester

Frederick

Garrett

Harford

Howard

Kent

Montgomery

Prince George's

Queen Anne's

St. Mary's

Somerset

Talbot

Washington

Wicomico

Worcester

12. Landline Phone:

Landline Phone:

13. Cell Phone:

Cell Phone:

14. Fax:

Fax:

15. Email address:

Email address:

16. Website address:

Website address:

17. Are you interested in receiving occasional emails from Maryland Family Network concerning child care and family issues?

Are you interested in receiving occasional emails from Maryland Family Network concerning child care and family issues? Yes