Exit this survey

1. Section 1

Please complete this application for your family child care home or group family child care site. If you have questions, please contact your lead agency or Ola Friday at (212) 652-2067.

Applications are due by February 19, 2010.

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* 1. Name of family child care site, if any

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* 2. Contact person

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* 3. Telephone and e-mail address of contact person

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* 4. Physical location

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* 5. Mailing address

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* 6. Hours open to serve children

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* 7. Days open to serve children

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* 8. License number(s) if applicable

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* 9. License capacity

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* 10. Total number of children enrolled

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* 11. Type of educational services offered (please check all that apply.)

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* 12. Total number of adults working with children

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* 13. Estimated number of children whose home language is not English

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* 14. Estimated number of children with special educational or medical needs

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* 15. Estimated number of children who have an IEP or ISFP

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* 16. Types of need-based financial assistance used by enrolled families to pay fees (please select all that apply)

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* 17. Estimated number of children receiving any need-based financial assistance to pay child care fees

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* 18. Years in operation at this site

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* 19. Affiliation, if any (please check all that apply)

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* 20. Accreditation status

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* 21. Your home or primary language(s)

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* 22. Other information about this site relevant to participation in the QUALITYstarsNY field test

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