NAME OF CENTER - GA Decal Bright from the Start
|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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