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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 them. 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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* Contact Information

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* Referrals

  Yes No
I would like CASY to refer families to my program.
I would like families to be able to contact me when they complete online referral searches.

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* Does child care staff speak more than one language fluently? If yes, please list below.

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* Accreditation

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

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

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* Does your program accept these funding sources?

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* Meals

  No Cost Additional Cost Parent must supply
Breakfast
Lunch
Snack
Dinner

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* Transportation

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* School(s) that participate with bus transportation to your program, or you provide transportation to/from:

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* Hours of Care

  Open Close
Same hours every Monday - Friday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

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* Extra Services Offered

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* Accepting

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* Duration

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* Vacancies per 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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* Weekly Rates

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* Age Range

  years months
From:
To:
Definitions
Licensed/Registered capacity - the capacity number on your license or registration.
Desired capacity - the number of children you are able to care for at this time while taking staffing, available space, or other factors into account. This number may be lower than licensed capacity.
Vacancies - total number of spots available at this time.

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* Capacity

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* Today's Date

Date

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* Financial Assistance Offered to Families

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* CCDF Details

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* Special Need(s) for which staff has experience, training or education.

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* Additional information, comments, questions?
Anything else you would like us to know about your program?

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* Are there resources you would like sent to you? 

Thank you for your time! 
Trisha Guinn
Program Engagement Specialist
tguinn@casyonline.org
(812) 231-8919
Schedule a meeting

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