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REGION ONE CHILD CARE PROVIDER PROFILE FORM · 2015-06-09 · REGION ONE CHILD CARE PROVIDER...
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Elementary School(s) Served: ___________________________ ___________________________ REGION ONE CHILD CARE PROVIDER PROFILE FORM 1-855-750-3343 • PO Box 2294 • Salina, KS 67402-2294 [email protected] • www.ks.childcareaware.org/one.html Contact and Vacancy Information Referral Preferences Yes No Web Referrals? q q Give Referrals? q q Print Rates on Referral Reports? q q Name Business Name License Number Street Address City, State, Zip Mailing Address Mailing City, State, Zip Primary Phone Secondary Phone Fax Email (optional) Website (optional) Receive Child Care Aware NEWS by email? Yes q No q Ages Served Minimum Age: _____ Years _____ Months _____ Weeks Maximum Age: _____ Years _____ Months _____ Weeks Total Desired Capacity _____________________________________ Total Vacancies ____________________________________________ Date of Vacancies __________________________________________ School/Transportation School District # Transportation To/From Available for Which Schools? ___________________________ ___________________________ Staffing/Languages Number of Staff Employed ___________________________ Languages Spoken ___________________________ ___________________________ SCHEDULE OPTIONS - Schedule 1 SCHEDULE DESCRIPTION (Check all applicable) o Day o Evening o Overnight o School Year Only o Summer/Holiday o Weekend Only o Preschool - 2 Day o Preschool - 3 Day o Preschool - 4 Day o Preschool - 5 Day o Full Time o Part Time o Both FT & PT o Drop-In o Temp/Emergency o Before School o After School o 24-Hour o Rotating o Open Holidays WAITING LIST? o Yes o No DATE OPENINGS AVAILABLE: _____________ RATES AGE FT PT Under 1 $ ______ $ _______ 1 - 1 1 / 2 $ ______ $ _______ 1 1 / 2 - 2 $ ______ $ _______ 2 $ ______ $ _______ 3 $ ______ $ _______ 4 $ ______ $ _______ 5 $ ______ $ _______ 6+ $ ______ $ _______ Rates are: q Hourly q Daily q Weekly q Monthly q None q Transportation Provided q To/From Preschool q On/Near School Bus Line q Field Trips q Near Public Bus Line q To/From Part Day School q To/From Client’s Home q To/From Full Day School q Within Walking Distance Check All Options Applicable: DAY: START: END: o Mon ________ ________ o Tues ________ ________ o Wed ________ ________ o Thurs ________ ________ o Fri ________ ________ o Sat ________ ________ o Sun ________ ________ Additional Fees: o Activities Fees o Field Trip Fees o Deposit o Late Fees o Enrollment Fees o Material Fees ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ ______ Under 1 1 - 1 1 / 2 1 1 / 2 - 2 2 3 4 5 6+ ______ ______ ______ ______ ______ ______ ______ ______ Age Group Desired Capacity DCF (previousy SRS) Capacity FT Vacancies PT Vacancies Vacancy Date Number Enrolled Child/ Adult Ratio
Transcript of REGION ONE CHILD CARE PROVIDER PROFILE FORM · 2015-06-09 · REGION ONE CHILD CARE PROVIDER...
Elementary School(s) Served:______________________________________________________
REGION ONE CHILD CARE PROVIDER PROFILE FORM
1-855-750-3343 • PO Box 2294 • Salina, KS [email protected] • www.ks.childcareaware.org/one.html
Contact and Vacancy Information
Referral Preferences Yes No
Web Referrals? q q
Give Referrals? q q
Print Rates on Referral Reports?
q q
Name
Business Name
License Number
Street Address
City, State, Zip
Mailing Address
Mailing City, State, Zip
Primary Phone Secondary Phone Fax
Email (optional)
Website (optional)
Receive Child Care Aware NEWS by email?
Yes q
No q
Ages Served
Minimum Age: _____ Years _____ Months _____ WeeksMaximum Age: _____ Years _____ Months _____ Weeks
Total Desired Capacity _____________________________________Total Vacancies ____________________________________________Date of Vacancies __________________________________________
School/Transportation
School District #
Transportation To/From Available for Which Schools?______________________________________________________
Staffing/Languages
Number of Staff Employed___________________________
Languages Spoken______________________________________________________
SCHEDULE OPTIONS - Schedule 1
SCHEDULE DESCRIPTION
(Check all applicable)o Dayo Eveningo Overnighto School Year Onlyo Summer/Holidayo Weekend Onlyo Preschool - 2 Dayo Preschool - 3 Dayo Preschool - 4 Dayo Preschool - 5 Dayo Full Timeo Part Timeo Both FT & PTo Drop-Ino Temp/Emergencyo Before Schoolo After Schoolo 24-Houro Rotatingo Open Holidays
WAITING LIST?o Yes o No
DATE OPENINGS
AVAILABLE:_____________
RATES AGE FT PTUnder 1 $ ______ $ _______1 - 11/2 $ ______ $ _______11/2 - 2 $ ______ $ _______2 $ ______ $ _______3 $ ______ $ _______4 $ ______ $ _______5 $ ______ $ _______6+ $ ______ $ _______Rates are: q Hourly q Daily q Weekly q Monthly
q Noneq Transportation Providedq To/From Preschool
q On/Near School Bus Lineq Field Trips
q Near Public Bus Lineq To/From Part Day School
q To/From Client’s Homeq To/From Full Day School
q Within Walking Distance
Check All Options Applicable:
DAY: START: END:o Mon ________ ________o Tues ________ ________o Wed ________ ________o Thurs ________ ________o Fri ________ ________o Sat ________ ________o Sun ________ ________
Additional Fees: o Activities Fees o Field Trip Fees o Deposit o Late Fees o Enrollment Fees o Material Fees
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
Under 1
1 - 11/2
11/2 - 2
2
3
4
5
6+
________________________________________________
Age
G
roup
Des
ired
Cap
acity
DC
F (p
revi
ousy
SR
S)
Cap
acity
FT
Vaca
ncie
s
PT
Vaca
ncie
s
Vaca
ncy
Dat
e
Num
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Enro
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Chi
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SCHEDULE OPTIONS - Schedule 2
SCHEDULE DESCRIPTION
(Check all applicable)o Dayo Eveningo Overnighto School Year Onlyo Summer/Holidayo Weekend Onlyo Preschool - 2 Dayo Preschool - 3 Dayo Preschool - 4 Dayo Preschool - 5 Dayo Full Timeo Part Timeo Both FT & PTo Drop-Ino Temp/Emergencyo Before Schoolo After Schoolo 24-Houro Rotatingo Open Holidays
WAITING LIST?o Yes o No
DATE OPENINGS
AVAILABLE:_____________
RATES AGE FT PTUnder 1 $ ______ $ _______1 - 11/2 $ ______ $ _______11/2 - 2 $ ______ $ _______2 $ ______ $ _______3 $ ______ $ _______4 $ ______ $ _______5 $ ______ $ _______6+ $ ______ $ _______Rates are: q Hourly q Daily q Weekly q Monthly
DAY: START: END:o Mon ________ ________o Tues ________ ________o Wed ________ ________o Thurs ________ ________o Fri ________ ________o Sat ________ ________o Sun ________ ________
Additional Fees: o Activities Fees o Field Trip Fees o Deposit o Late Fees o Enrollment Fees o Material Fees
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
Under 1
1 - 11/2
11/2 - 2
2
3
4
5
6+
________________________________________________
Age
G
roup
Des
ired
Cap
acity
DC
F (p
revi
ousy
SR
S)
Cap
acity
FT
Vaca
ncie
s
PT
Vaca
ncie
s
Vaca
ncy
Dat
e
Num
ber
Enro
lled
Chi
ld/
Adu
lt R
atio
Special Needs
o ADHD/ADD/PDDo Abuse & Neglect (witness/victim)o Allergieso Apnea Monitoro Asthmao Autism/Aspergero Cerebral Palsyo Cystic Fibrosiso Developmental Delayso Diabeteso Downs Syndromeo Emotional Delayso Epilepsy/Febrile Seizureso Gastrostomy/Tube Feedingo HIV/AIDSo Hearing Impairedo Maternal Substance Abuseo Medically Fragileo Mental Illnesso Nutritional Deficiencieso Visual Impairmento Other: ___________________
________________________
Attributes
o ADA Accessible Indooro ADA Accessible Outdooro Above or In-Ground Poolo Air Conditioningo Air Purifiero Basement Used as Storm Sheltero Basement Used for Child Careo Dehumidifiero Designated Indoor Play Area (FCC)o Fenced Yard
o No Petso Non-Carpeted Environmento Outdoor Pets Onlyo Small Group of Six or Fewer
Childreno Smoke Freeo Smoking During Non-Business
Hours Onlyo Wading Pool
Meals
o CACFP Food Programo Serves Breakfasto Serves Morning Snacko Serves Luncho Serves Afternoon Snacko Serves Evening Mealo Serves Evening Snacko Supports Breast Milko Provides Infant Formula and
Infant Foodo Special Diet
Policies
o Written Agreement/Contracto Written Handbooko Billing Weeklyo Billing Monthlyo Billing on 1st for Entire Montho Billing Bi-Monthlyo No Notice Required When
Family Resignso Less Than 1 Week Notice
Required if Family Resignso One Week Notice Required if
Family Resignso Two Weeks Notice Required if
Family Resigns
Experience
o Under 1 Yearo 1-3 Yearso 4-9 Yearso 10-20 Yearso More than 20 Yearso Family Child Careo Child Care Centero Preschoolo Elementary Schoolo Para
Training
o No Professional Development o 1-5 In-Service Hourso 6-10 In-Service Hourso 11-20 In-Service Hourso More than 20 In-Service Hourso .4-2 CEUso 3-6 CEUso 7-10 CEUso More than 10 CEUso Early Childhood College Credits
Affiliation
o NAFCCo State FCC Associationo Local FCC Association
o NAEYCo State AEYCo Local AEYC
Safety
o CPR Current Within 2 Yearso Child Care Health Consultant
Agreemento First Aid Training Within Past
12 Monthso Liability Insurance Covering
Child Care Businesso On-Site Nurse
Philosophy
o Creative Curriculumo Developmentally Appropriate
Practiceso High Scopeo Montessorio No Curriculum Usedo No Televisiono Own Curriculum Usedo Reggio Emilia Inspiredo Religious Curriculumo Waldorf
Special Skills
o Teaches Spanisho Teaches Sign Language
Advocacy
o Member of Child Care Aware® of Kansas
o Member of NAEYC/KAEYC or local AEYC affliate
o Member of Providers’ Groupo Member of CCPCo Participant in Advocacy
Conferences
o Participant in Local Advocacy Events
o Visit with Legislatorso Write Legislatorso On Mailing List for Legislative
Issues
Education (Check Highest Level Completed for All Staff)
o Some High Schoolo High School Diploma or GEDo Associate in Early Childhoodo Associate in Non-Early Childhoodo Bachelor in Early Childhood
o Bachelor in Non-Early Childhoodo Master in Early Childhoodo Master in Non-Early Childhood o Doctorate in Early Childhoodo Doctorate in Non-Early Childhood
Accreditation
o NAFCCo NAEYC
o NECPo NACCP
Financial Options
o Foster Care / Adoptiono KCSLo Local Financial Assistanceo Militaryo Multi-Child Discount
o Department of Children and Families (DCF), previously SRS
o Scholarshipso Sliding Scale / Non-DCFo Youthville
Early Education College Credits
o 0 o 1-6o 7-12o 13-24o 25-48
o 49-72o 73-96o 97-120o More than 120
Type of CDA (Child Development Associate) List Names of Staff Currently Holding CDAs
o Center Based Infant/Toddler1. ______________________________2. ______________________________3. ______________________________
o Preschool1. ______________________________2. ______________________________3. ______________________________
o Family Child Care1. ______________________________2. ______________________________3. ______________________________
Professional Development
o EBT (Electronic Benefit Transfer)o Q-Tip Oh! Filling the Gapo DYFCCB (Developing Your
Family Child Care Business)o Infant/Toddler Professional
Developmento NACCRRA Conference
o Child Care Aware® of Kansas Statewide Professional Development
o CCR&R Sponsored Professional Development
o KCCTO
Intentionality Why You Work in Early or School Age Ed Programs
o Career or Professiono Stepping Stone to a Related
Careero Personal Callingo Job With Paycheck
o Work to Do While My Children are at Home
o Way of Helping a Family Member, Neighbor or Friend
Core Competency Area (Listed on Class Certificates)
o I. Child Growth & Developmento II. Learning Environment and
Curriculumo III. Child Observation and
Assessmento IV. Families and Communities
o V. Health, Safety and Nutritiono VI. Interactions with Childreno VII. Program Planning and
Developmento VIII. Professional Development
and Leadership
Program Participation
o ACCYN (Army Child Care in Your Neighborhood)
o Apprenticeshipo ELOAo Early Head Starto KQRIS
o Smart Starto T.E.A.C.H.o CCO (Child Care Online)o WAGE$
CONFIDENTIAL INFORMATIONThe following information is collected for statistical purposes only.
THIS SECTION IS FOR FAMILY CHILD CARE PROVIDERS ONLY. ALL OTHERS CONTINUE TO NEXT PAGE.
o Houseo Townhomeo Duplex
o Apartmento Mobile Homeo Non-Residential
CHILD CARE SETTING
o Health Insuranceo Dental Insuranceo Life Insuranceo Sick Leaveo Vacationo Retirement
o Professional Development Leave
o Long-Term Disabilityo Short-Term Disabilityo Vehicle Insurance
BENEFITS
What is your annual net income from your child care business?o Under 5,000o 5,000 - 9,999o 10,000 - 14,999o 14,000 - 19,999o 20,000 - 24,999
o 25,000 - 29,999o 30,000 - 34,999o 35,000 - 39,999o 40,000 - 44,999o 45,000 - 49,999o 50,000 - 54,999o 55,000 - 59,999o Other _________________
WAGES
Is the business owner Spanish/Hispanic/Latino? o Yes o NoRace:______________ Ancestry or Ethnic Origin?___________Is a non-English language used in your home? o Yes o NoWhat Language(s)? ____________________________________
CENSUS QUESTIONS
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
COMMENTS?
Date Completed:
Signature:
Completed By (please print):
CONFIDENTIAL INFORMATIONThe following information is collected for statistical purposes only.
THIS SECTION IS FOR CHILD CARE CENTERS ONLY.
o Non-Residential o Faith Based o Workplace Basedo Residential o School Based o Military Basedo Tribal Based o Campus Based o Summer CampNumber of Classrooms _________________________________
BUSINESS SETTING
Number of Persons on Staff Who Are________ Mexican, Mexican American, Chicano________ Puerto Rican________ Cuban________ Other Spanish/Hispanic/Latino Specify: ___________
Number of Persons on Staff Whose Race Is________ White________ Black/African American________ Amer. Indian/Alaska Native Specify Tribe: _________________ Asian Indian________ Native Hawaiian________ Chinese________ Filipino________ Japanese________ Vietnamese________ Other Asian Specify: ________________________________ Guamanian or Chamorro________ Samoan________ Other Pacific Islander Specify: ________________________ Other Race Specify: ________________________
CENSUS QUESTIONS _________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
COMMENTS?
Date Completed:
Signature:
Completed By (please print):
STAFFING INFORMATION
Number of staff who use a non-English language at home ______What language(s)? ____________________________________How well do these persons speak English?o Very Well o Well o Not Well
ENGLISH ABILITY
Low Pay $ _________ High Pay $ _________ Pay Rate is: o Hourly o Monthly o Annually
Benefits for this position: o Health o Dental o Retirement o LIfe o Vacation o Sick Leave o L/T or S/T Disability o Prof Dev Leave o Company Vehicle/Vehicle Insurance
Administrator
Low Pay $ _________ High Pay $ _________ Pay Rate is: o Hourly o Monthly o Annually
Benefits for this position: o Health o Dental o Retirement o LIfe o Vacation o Sick Leave o L/T or S/T Disability o Prof Dev Leave o Company Vehicle/Vehicle Insurance
Director
Low Pay $ _________ High Pay $ _________ Pay Rate is: o Hourly o Monthly o Annually
Benefits for this position: o Health o Dental o Retirement o LIfe o Vacation o Sick Leave o L/T or S/T Disability o Prof Dev Leave o Company Vehicle/Vehicle Insurance
Assistant Director
Low Pay $ _________ High Pay $ _________ Pay Rate is: o Hourly o Monthly o Annually
Benefits for this position: o Health o Dental o Retirement o LIfe o Vacation o Sick Leave o L/T or S/T Disability o Prof Dev Leave o Company Vehicle/Vehicle Insurance
Program Director
Low Pay $ _________ High Pay $ _________ Pay Rate is: o Hourly o Monthly o Annually
Benefits for this position: o Health o Dental o Retirement o LIfe o Vacation o Sick Leave o L/T or S/T Disability o Prof Dev Leave o Company Vehicle/Vehicle Insurance
Lead Teacher
Low Pay $ _________ High Pay $ _________ Pay Rate is: o Hourly o Monthly o Annually
Benefits for this position: o Health o Dental o Retirement o LIfe o Vacation o Sick Leave o L/T or S/T Disability o Prof Dev Leave o Company Vehicle/Vehicle Insurance
Assistant Teacher
Low Pay $ _________ High Pay $ _________ Pay Rate is: o Hourly o Monthly o Annually
Benefits for this position: o Health o Dental o Retirement o LIfe o Vacation o Sick Leave o L/T or S/T Disability o Prof Dev Leave o Company Vehicle/Vehicle Insurance
Co-Teacher
Low Pay $ _________ High Pay $ _________ Pay Rate is: o Hourly o Monthly o Annually
Benefits for this position: o Health o Dental o Retirement o LIfe o Vacation o Sick Leave o L/T or S/T Disability o Prof Dev Leave o Company Vehicle/Vehicle Insurance
Non-Teaching Staff
