Application to Participate in the QUALITYstarsNY Field Test

Please complete one application for each site – the physical location where early care and education services are provided. If you have questions, please contact your lead agency or Ola Friday at (212) 652-2067.

Applications are due by February 19, 2010.

1. Name of school or agency

Name of school or agency

2. District or agency contact person

District or agency contact person

3. Telephone and e-mail address of district or agency contact

Telephone and e-mail address of district or agency contact Telephone
E-mail

4. Name of program or classroom site

Name of program or classroom site

5. Site contact person

Site contact person

6. Telephone and e-mail address of site contact person

Telephone and e-mail address of site contact person Telephone
E-mail

7. Physical location of program or classroom site

Physical location of program or classroom site Street Address
City
Zip Code

8. Mailing address of program or classroom site

Mailing address of program or classroom site Address
City
Zip Code

9. Hours program or classroom is open to serve children

Hours program or classroom is open to serve children Opening Time
Closing Time

10. Types of sessions offered (please check all that apply.) If the program is in a school, do not included kindergarten or other grade sessions.

Types of sessions offered (please check all that apply.) If the program is in a school, do not included kindergarten or other grade sessions. Morning session

Afternoon session

Full-day session

School-year (September - June) session

Full-year session

11. Organization operating program or classroom site (please check one).

Organization operating program or classroom site (please check one). Public School

Private School

Non-profit Organization

For-profit Organization

Other (please specify)

12. NY regulating agency

NY regulating agency NYS Office of Children and Family Services (OCFS)

NYS Education Department (SED)

NYC Department of Health and Mental Hygiene (DOHMH)

13. License number(s) if applicable

License number(s) if applicable 1
2
3
4
5

14. License capacity

License capacity Infants/Toddlers
Preschool
School-Age Care

15. Total number of children enrolled (if a program is in a school, do not included kindergarten or other grades).

Total number of children enrolled (if a program is in a school, do not included kindergarten or other grades). Infants/Toddlers
Preschool
School-Age Care

16. Total number of classrooms (if a program is in a school, do not included kindergarten or other grades).

Total number of classrooms (if a program is in a school, do not included kindergarten or other grades). Infants/Toddlers
Preschool
School-Age Care

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

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

Other preschool

Head Start

Early Head Start

Special needs classroom

Integrated classroom with special needs children

Other (please specify)

18. Total number of teachers (if the program is in a school, do not included kindergarten or other grade teachers.)

Total number of teachers (if the program is in a school, do not included kindergarten or other grade teachers.)

19. Total number of assistant teachers, aides, or other classroom staff (if the program is in a school, do not included kindergarten or other grade teachers.)

Total number of assistant teachers, aides, or other classroom staff (if the program is in a school, do not included kindergarten or other grade teachers.)

20. Estimated percent of children whose home language is not English

Estimated percent of children whose home language is not English

21. Estimated percent of children with special educational or medical needs

Estimated percent of children with special educational or medical needs

22. Estimated percent of children who have an IEP or ISFP

Estimated percent of children who have an IEP or ISFP

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

Types of need-based financial assistance used by enrolled families to pay program fees (please select all that apply) No fees are charged to attend programs at this site

No need-based assistance is available at this site

Scholarships

Sliding fee scale

Public child care subsidies or vouchers (payments received for child care services from the local department of social services)

Other (please specify)

24. Estimated percent of children receiving any need-based financial assistance

Estimated percent of children receiving any need-based financial assistance No fees are charged to attend programs at this site

No children receive need-based financial assistance to pay program fees

Estimated percent

25. Years in operation at this site

Years in operation at this site

26. Program affiliation, if any (please check all that apply)

Program affiliation, if any (please check all that apply) College/University

Employer-sponsored

Faith-based institution

Hospital

Military installation

Indian tribe

Parent cooperative

US government facility

State government facility

Public housing

Community Action (CAP) agency

Other (please specify)

27. Accreditation status

Accreditation status None

Currently accredited by NAEYC -- please give accreditation # & date:

Currently accredited by another national organization – please list accrediting body(ies), accreditation #(s), and date(s):

Accreditation body(ies), numbers and dates

28. Primary language(s) used by most of program staff

Primary language(s) used by most of program staff English

Spanish

Other (please specify)

29. Other information about this program site relevant to participation in the QUALITYstarsNY field test

Other information about this program site relevant to participation in the QUALITYstarsNY field test

Application to Participate in the QUALITYstarsNY Field Test - School- or Center-based Sites

1. Section 1

1. Name of school or agency

2. District or agency contact person

3. Telephone and e-mail address of district or agency contact

4. Name of program or classroom site

5. Site contact person

6. Telephone and e-mail address of site contact person

7. Physical location of program or classroom site

8. Mailing address of program or classroom site

9. Hours program or classroom is open to serve children

10. Types of sessions offered (please check all that apply.) If the program is in a school, do not included kindergarten or other grade sessions.

11. Organization operating program or classroom site (please check one).

12. NY regulating agency

13. License number(s) if applicable

14. License capacity

15. Total number of children enrolled (if a program is in a school, do not included kindergarten or other grades).

16. Total number of classrooms (if a program is in a school, do not included kindergarten or other grades).

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

18. Total number of teachers (if the program is in a school, do not included kindergarten or other grade teachers.)

19. Total number of assistant teachers, aides, or other classroom staff (if the program is in a school, do not included kindergarten or other grade teachers.)

20. Estimated percent of children whose home language is not English

21. Estimated percent of children with special educational or medical needs

22. Estimated percent of children who have an IEP or ISFP

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

24. Estimated percent of children receiving any need-based financial assistance

25. Years in operation at this site

26. Program affiliation, if any (please check all that apply)

27. Accreditation status

28. Primary language(s) used by most of program staff

29. Other information about this program site relevant to participation in the QUALITYstarsNY field test