* 1. Enter the name of the child care program that you are submitting information on:

* 2. Enter the address location of the child care program:

* 4. Is your child care program currently open and caring for children?

* 5. Select the reason your program is now closed:

* 6. Would you like to be included in referrals given to families who contact us looking for child care?

* 7. Enter the first and last name of the individual parents should ask for when looking for child care:

* 8. Has there been any phone number changes for the program? If so enter them in the space below.

* 9. Is there another email address that we should use for communication about the child care program?

* 10. Are you currently caring for any families active in the military? If Yes, enter an approximate number in the space below:

* 11. Are you willing to provide flexible scheduling for military families?

* 12. Does your child care program have non-profit status?

Your program is considered 'non-profit’ if it has current 501c3 tax exempt status.

* 13. Enter the days of the week and the hours that the program is open.

* 14. Is your program willing to provide either of the following to families:

* 15. Does your program offer any of the following services?
Select all that apply.

* 16. Have there been any changes in the ages of children that your program serves?

* 17. Select the meals that your program serves, and whether they are at no cost or an additional cost to families:

  No Cost Additional Cost Not Served
Snacks
Breakfast
Lunch
Dinner

* 18. Environmental Factors in Program: For each item, select whether it is present in the child care environment:

  Yes No
Enclosed Outdoor Play Area (fenced play area)
Pool or Waterfront
Pets Present (any living species)
Wheelchair Accessible
Separate Care Area - Family Child Care Homes - Care separate from family living quarters

* 19. Select the option that best describes the physical setting of the child care program:

* 20. Enter the current rate options that you charge families. If you do not care for any age group category below, leave field blank:

* 21. Enter the total number of children you currently have enrolled in each age group:

* 22. Enter the total number vacancies your program has for each age group. (If age groups are combined in your program, enter approximations).

* 23. Has there been any other changes in your program that you would like to tell us about? Please explain in the space provided:

* 24. Does your program currently provide programming for K – 12 youth?

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