* 1. Please list your current contact information below.

* 2. Licensing information (You can refer to you EEC license to find this information) If your program is excempt simply type excempt in the program number field.

* 3. Please complete the information below regarding ages of children and current vacancies.

* 4. What are your days and hours of operation?

* 5. What do you charge families? Please enter your rate information by age group

* 6. Please select all that apply to you childcare program environment.

* 7. What type(s) of financial assistance do you accept? (Please check all that apply)

* 8. Do you have experience and / or training in any of the following special needs? Please check all that apply.

* 9. Please describe your program and/or what type of activities you offer the children? (This is shown on the profile of your program given to parents.)

* 10. What QRIS level is your program at?