è For Parents

è For Providers of Child Care

è For the Community

Home-Based Program Update

Part of a state-wide network of referral agencies, Child Care Connection serves Mahoning, Medina, Portage, Summit, Stark, and Trumbull Counties in Ohio.

 


Which version do you want?

  • The form below must be completed and submitted before you end your internet session. Simply tab, type your information, and the click the [Submit] button.

  • Click here if you want to save it to your computer and complete it later in Microsoft Word.

  • Click here if you want to print out the PDF version and write in your answers.


 

Family Child Care Information Form

Date:
Name:
Business Name:
Email:
Address:
City/State/Zip:
Phone:
Fax Number:
County:
Mailing Address
(include City & Zip):

CHECK ALL THAT APPLY REGARDING YOUR SERVICES.  YOU MAY CHECK MORE THAN ONE ITEM.
Are You Certified? Yes   No     If yes, what county?
What are the ages of the children in your care?     From: To:

SCHEDULES:

 

 

Regular
 Full-time care
 Part-time care
 Rotating schedules

 Yearly
 Full Year care
 Vacations/Holidays
 Summer care
 School Year		 Special Services
 Drop-in care            24 hour care
 Sick care               Respite care
 Flexible Hours
Temporary/emergency/backup care

 

SCHOOL-AGE CARE:

 
Will you provide before and after school care?   Yes   No
If yes, what elementary school(s) are closest to you?
Do you provide transportation?  Yes     No
If yes, check all that apply:         To/From School         To/From Child's home

If you don't provide transportation, how do children get to and from school? (walk, school bus, etc.)

DAYS/HOURS OF OPERATION: (check all that apply and fill in hours)
Monday... Hours From: To:
Tuesday... Hours From: To:
Wednesday... Hours From: To:
Thursday... Hours From: To:
Friday... Hours From: To:
Saturday... Hours From: To:
Sunday... Hours From: To:

VACANCIES: (HOW MANY VACANCIES?)

    Day:   Evening:  Overnight:

MEALS:
Breakfast Morning Snack Special Diet
Lunch Afternoon Snack Parent Provided
Dinner Evening Snack  

ENVIRONMENT:
Non-smoking Gym No pets
Outdoor play area Wheel-chair accessible Has a pool
Fenced yard Near public transportation Has pets indoors,
    List pets:

EDUCATION: (check highest level achieved)

High School Diploma/GED

4 year degree

Some college/No degree

2 year degree

CDA Completed

Masters degree

CDA in progress

 

PROFESSIONAL TRAININGS: (check all that apply)
First Aid CPR Child Abuse Recognition
Nutrition Early Childhood Communicable Disease

EXPERIENCE:

How many years experience do you have in childcare?
 0 - 1 year
 1 - 3 year(s)
 4 - 9 years
 10 - 20 years
 Over 21 years

Do you have experience caring for children with special needs?
 Yes     No
(If yes, check all that apply.)
 Emotional/Behavioral
 Physical-Mobility
 MRDD
 Speech/Hearing
 Medical Conditions

FEES:

                  HOURLY

DAILY

 WEEKLY
Infants
Toddlers
Preschool Age
School-age: B/A school
Summer Rate
Holiday Rate
I wish to receive referrals from Child Care Connection Yes     No
Do you offer a multiple child discount? Yes     No
Do you have a partnership with HeadStart? Yes     No
Are you enrolled in the Child & Adult Food Program? Yes     No
If no, would you like information on the Child & Adult Food Program? Yes     No
Yes, I have read and understand the policies and procedures for referrals and complaints established by Child Care Connection.
 

Provider's Name
 

Click on the button below to Submit your form to:
Child Care Connection
703 South Main Street # 211
Akron, Ohio  44311
 

 

Part of a state-wide network of referral agencies, Child Care Connection serves Mahoning, Medina, Portage, Summit, Stark, and Trumbull Counties in Ohio.

© 2001-2005 Child Care Connection Akron OH  44304. All rights reserved.

Child Care Connection is a program of Info Line, Inc
703 South Main Street # 211 • Akron, OH • 44311
330-376-7706 • 1-800-407-KIDS (5437)
Funded by United Way and the Ohio Department of Job and Family Services