NAME OF CENTER



|Consultant Name: |Region: |

|NAME OF CENTER |      |

|LEGAL NAME |      |

|LICENSE NUMBER |      |

|Type of Ownership |

|Corporation Individual Partnership Limited Liability Corp (LLC) |

|Board Sponsored Governmental Association |

|If owned by Inc. or LLC – Compliant with Secretary of State Yes No |

|Address: |Center Telephone # |      |

|      | | |

| |Center Fax # |      |

|City |State |Zip Code |County |

|      |      |      |      |

|Mailing Address (if different) |

|Address |

|      |

|City |State |Zip Code |County |

|      |GA |      |      |

|Email Address:       |

|Additional Information: |

|Director: Mr. Ms. Mrs.       |

|FEIN # (for centers owned by corporations)       |

|GA Pre-K: Yes No Early Head Start: Yes No # of children _________ |

|Head Start: Yes No # of children _________ |

|Accreditation Status: NAFCC NAEYC CAO SACS ACSI AMS AMI QR GAC APPLE MSAC IMC GPSAC GACS SAIS NECPA NAC|

|ELEA NLSA Other ____________________ |

|Operational Information: |

|Months of Operation: ALL January February March April May June July August September October November December |

| |

|Days of Operation: Monday Tuesday Wednesday Thursday Friday Saturday Sunday All |

| |

|Hours of Operation:       am/pm to       am/pm       am/pm to       am/pm (Weekend Hours) |

|35 sq ft Capacity:       25 sq ft Capacity:       |Certificate of Occupancy Capacity:       |

|Ages Served: |

| Infant (0-12 months) Rate $_______________ | Toddler (13 mos – 2 yrs) Rate $________________ |

| Preschool (3 yrs – 4 yrs) Rate $_______________ |School Age (5 yrs or older) Rate $_________________ |

|GA Lottery Pre-k (4 yrs) Fees $_______________ | |

|Services Provided: |

| Evening/Night Care | Accepts Childcare Subsidies | Drop-In Care | Transportation To/From School |

| |(DFCS/CAPS) | | |

| After School Only | Transportation To/From Home | School-age Summer Care | CACFP/SFSP |

| Other       | | | Liability Insurance |

|Comments: |

|Staff Profile |

|Personal Data |Qualifications |Training |

|Staff Name |

|Positions |L: Lead, A: Assistant, D: Director, C: Cook, V: Van Driver, CL: Clerical, P: Provider (FCCLH) |

|Staff Application/ File |Application should include a completed application and 10-year work history |

| |Complete file should include copies of all items listed above |

|CBC |Verification of staff person’s Comprehensive Background Check |

|Education |Copy of degree or education plan if currently in progress |

|First Aid/CPR |First Aid certification is good for 3 years, CPR certification is good for 2 years |

|Food Prep Training |Required for cooks and Directors |

|Transportation Training |Required for all drivers and Directors; drivers license should be current and for applicable vehicle type |

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