CASY 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 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:

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* Name as listed on License/Registration:

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* State License Number/Facility ID:

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* State License/Facility ID Expiration Date:

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* Please provide the site information:

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* Please provide contact information:

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* Please provide the mailing address ONLY if it is different from the location address above.

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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:

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* Please provide your current openings for each age group:

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* Please provide your current enrollment for each age group:

Please enter your current rate information below. Note: Rate information is never provided to the families looking for care. We collect rate information to provide to the FSSA Office of Early Childhood & Out-of-School Learning during Market Rate surveys. It is important to have up to date records of rates for programs in order to base an average cost of care for the county you serve.

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* Please enter the amount charged for Infants: Age Range 0-12 months:

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* Please enter the amount charged for Toddlers: Age Range 13-23 months:

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* Please enter the amount charged for Toddlers: Age Range 24-35 months:

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* Please enter the amount charged for Preschoolers: Age Range 3-4 years:

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* Please enter the amount charged for Preschoolers: Age Range 5 years:

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* Please enter the amount charged for School Age: Kindergarten:

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* Please enter the amount charged for School Age: Before/After only:

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* Please enter the amount charged for School Age: Summer Care:

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* Have there been any changes to your hours of operation, meals served, transportation, etc. since your last update? If you are unsure if changes have occurred since your last update, please select yes and complete the information below. We will verify the information within your program file.

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* Accepts Children:

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* Duration:

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* Extra Services:

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* Does your program accept either type of funding?

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* Schools Served:

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* School District:

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* Transportation, if available:

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* Does child care staff (who care for the children) speak any of the following languages fluently:

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* Environmental features of your child care program (select all that apply):

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* Please list what meals are served in your facility?

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* Are you currently participating in the CACFP (Child & Adult Care Food Program)?

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* Is your program accredited?

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* Select any Special Need(s) for which staff within your program has training or education:

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* Select any of the following financial assistance options your program offers to families:

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* Which option best describes the physical setting of your child care program:

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* Does your child care program provide care ONLY for any of the following groups?

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* Additional Fees:

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* Additional comments, services, or resources?

Thank you for your time!

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