Provider Update Survey

The following survey is an alternative to updating your child care profile over the phone. If you prefer over the phone, you may call the 4C office at 812-423-4008, option 3 and complete the update over the phone.

If you have more than one child care, please fill out a separate survey for each child care.

If you have any problems filling out the survey, please call our office at 812-423-4008, option 3 or Ashley Hansen ext. 108. You may also e-mail Ashley at ahansen@child-care.org.

1.Enrollment Contact of Child Care and Child Care Business Name. Enrollment contact is the person that families looking for child care will contact.(Required.)

First Name

Last Name

Business Name

3.Would you like 4C to include your child care in referrals to parents?(Required.)

Yes

No

4.Location/Mailing Address and Contact Information of Child Care(Required.)

Child Care Street Address

City

State

Zip

County

Mailing Address (if different from above)

City

State

Zip

Primary Phone

Secondary Phone

Fax Number

Email Address

Website

5.License Type(Required.)

I am a licensed Child Care Center Indiana Family and Social Services Administration

I am a licensed Family Child Care Home Indiana Family and Social Services Administration

I am a ministry registered through the Indiana Family and Social Services Administration

I am a ministry registered through the Bureau of Child Care and have met the Voluntary Certification Program (VCP) Standards

I am operating a program that is exempt from licensure and/or registration.

6.Capacity. License Capacity is the capacity on your license. If your facility is not licensed, leave this blank.

Desired Capacity is the total number of children you desire to have in your child care. This number may be lower than License Capacity.(Required.)

Total License Capacity

Total Desired Capacity

Total Vacancies

7.Accepted Age Range(Required.)

Age

Lowest Age Accepted

Highest Age Accepted

Other (please specify)

8.Hours of Child Care. If you have more than one shift, please indicate the time the child care opens until the time the child care closes. If child care is 24 hours, start time is 12:00am and end time is 11:59pm.(Required.)

Number of Shifts

Start Time

End Time

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

9.Accepts Children:(Required.)

Part Time

Full Time

Both

10.Rates (based on ages of children). (Required.)

Weekly Rate, Part Time

Weekly Rate, Full Time

School Age Children (Summer and Holidays)

0-12 Months

13-23 Months

24-35 Months

3-4 Years

5 Years

Kindergarten

Before and After School

11.Capacity/Vacancy/Enrollment Information by Age. Please only fill in answers for ages of children your child care accepts. Leave all other ages blank.(Required.)

Full Time Vacancies

Part Time Vacancies

# Enrolled

School Age Children (Holidays and Summer)

0-12 Months

13-23 Months

24-35 Months

3-4 Years

5 Years

Kindergarten

Before and After School

14.Child and Adult Care Food Program (CACFP) Participation:(Required.)

Participating

Not Participating

15.Select any of the following financial assistance options your program offers to families:(Required.)

Approved for CCDF Vouchers

Multi Child Discount - discounted fees for families with multiple children

Sliding Fee Scale - fees based on family income levels

Scholarships

Employer/College Supported Discounts - discounted fees for families from specific employers or colleges

None of the above

Provider Update

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