Group Day Care - Child Care Choices of Boston



[pic]FAMILY CHILD CARE PROVIDER PROFILE

Date Profile Completed: __________________ Completed By: _________________________

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General Info First Name: ___________________ Last Name: _________________________

Business Name: ______________________________________________________________________

(If applicable)

|Type of Care: |( Family Child Care | Date license first issued: |_____________________ |

When you have vacancies, do you want CCCB to refer parents to your program? Yes No

Location Address: __________________________________________________________________

(Do not put Post Office Boxes here.)

City: _______________________________________ State: ____________ Zip: ________________

Mailing Address: _______________________________________________________________________________

(If different from above.)

City: _______________________________________ State: ____________ Zip: ________________

Contact Primary phone: _____________________ Secondary phone: ___________________

Fax Number: _____________________ Email Address: _________________________

Website: __________________________________________________________________

License Information

Program # (ID): _____________________ Your Tax ID number: _____________________

License Number: _____________________ License Expiration Date: ____________________

What is the total licensed capacity for your program as stated on your EEC license: _________

If you choose to accept fewer children than your licensed capacity, what is the

maximum number of children you would enroll at any one time? _________

What is the total number of children currently enrolled full-time at your program: _________

(full-time is 30 or more hours per week)

What is the total number of current full-time vacancies (capacity – enrollment): _________

What ages of children will you accept at your program?

From: ____years ____months To: ____years ____months

(from the youngest you would accept to the oldest you would accept)

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Transportation: Please check any of the following that apply.

| Walking distance to school | Near public transportation | |

| One-way transportation provided | Two-way transportation provided | On school bus route |

Languages: Please check all languages spoken by you or your staff.

| English | American Sign Language | Amharic |

| Armenian | Cantonese | Chinese (Mandarin)Polish |

| Croatian | French | Greek |

| Italian | Khmer (Cambodian) | Laotian |

| Polish | Portuguese | Russian |

| Serbian-Cyrillic | Slovenian | Spanish |

| Vietnamese | Other: _____________ | |

| |

|Schedule Options: Please check all that apply to your program: |

| Part-week | Part day | Full day |

| 2nd Shift (approx 3pm-11pm) | 3rd Shift (approx 11pm-7am) | Sick care |

| Evening (after 6pm) | Overnight | Early day |

| Open school vacation weeks | Full week | Weekend |

| Flexible Schedule | Morning Session | Afternoon session |

| | |

|Are you subcontracted with a family child care system? |Yes No |

|If yes, check the appropriate System Agency below: (Check ONE only) |

| Associated Early Care & Education, Inc. | Clarendon Family Day Care |

| Bethel Child Care | Family Day Care Program, Inc. |

| Boston Chinatown Family Child Care | FDNH-Bartholomew |

| Child Care Project | Little Sisters of Assumption (Project Hope) |

| Child Development and Education, Inc. | JPNDC (Neighborhood Development Corp of Jamaica Plain) |

| Children’s Services of Roxbury | Viet Aid |

| Other:_______________________________________________________________________ |

|Do you also serve children outside the System (i.e. some private paying families)? | Yes No |

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Days Care Provided

|Is your program open: | Full year | School year only | Summer only |

|Do you accept children: | Both full-time | Full-time only | Part-time only |

| |and part-time |(30 or more hours per week) |(less than 30 hours per week) |

|Please check any of the following additional schedule options you offer: |

| | Before School | After School | Open Holidays |

| | Drop in | Rotating Schedule | 24-Hour Care |

| | Temporary/Emergency Care | |

|Please check the days that your provide care and indicate what time you open and close: |If you do an additional after school or evening schedule, |

| |please indicate it here: |

| | |Start Time |End Time |Start Time |End Time |

| |Monday |_______________ |_______________ |_______________ |_______________ |

| |Tuesday |_______________ |_______________ |_______________ |_______________ |

| |Wednesday |_______________ |_______________ |_______________ |_______________ |

| |Thursday |_______________ |_______________ |_______________ |_______________ |

| |Friday |_______________ |_______________ |_______________ |_______________ |

| |Saturday |_______________ |_______________ |_______________ |_______________ |

| |Sunday |_______________ |_______________ |_______________ |_______________ |

What do you charge for private paying (non-voucher) families based on the following age categories?

(You may attach a copy of published rates/documents you provide to parents outlining your fees.)

Check here if you do not have a private rate (i.e. you only take children with vouchers or through a system agency).

|Age Group |Full Time |Part-Time |

| |Weekly Rate |Hourly Rate (if applicable) |

|Infant |$_____________ per week |$_____________ per hour |

|(0-14 Months) | | |

|Toddler |$_____________ per week |$_____________ per hour |

|(15 Months-2 Years) | | |

|Preschool |$_____________ per week |$_____________ per hour |

|(over 2 years) | | |

|Part-time School Age |$_____________ per week |$_____________ per hour |

|(6-12 Years) | | |

Additional Fees

Please check and indicate amounts for any additional fees you may charge:

| Registration Fee | Late Fee | Extended Care Fee |

| Waitlist Fee | Materials Fee | Activities Fee |

Please use this space to make any special notes regarding the rates/cost for your program: _____________________________________________________________________________________

______________________________________________________________________________________________________

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Enrollment Information

|Please list the ages of all children currently enrolled FULL-TIME: |

|_______years_______months. |_______years_______months. |_______years_______months. |

|_______years_______months. |_______years_______months. |_______years_______months. |

|_______years_______months. |_______years_______months. |_______years_______months. |

| | |_______years_______months. |

|Please indicate if you have any part-time vacancies and for which age groups: | |_______years_______months. |

|Age Group |Part-time Vacancies |

|Infant (0-14 Months) |_____________ |

|Toddler (15 Months-2 Years) |_____________ |

|Preschool (over 2 years) |_____________ |

|School Age (6-12 Years) |_____________ |

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Attributes

Check here if you provide RESPITE care.

Environment: Please check all that apply.

| Accepts cloth diapers | Adult Pool | Air Conditioned |

| Approved Assistant | Cats | Dogs |

| Fenced Yard | Field Trips Taken | No pets |

| Other pets | Peanut Free | Smoke Free |

| Uses Public Playground | Wheel Chair Accessible | |

Meals: Please check all meals that are provided and/or what applies for your program.

| Breakfast | Morning Snack | Lunch |

| Afternoon Snack | Dinner | USDA Food Program |

| Special Meal Request | Parents Provide Food | Parents Provide Lunch |

Philosophy: Please check all that apply to your program.

| Academic Program | High/Scope Approach | Learning/Play |

| Montessori | Parent Cooperative | Piaget |

| Reggio Emilia | Religious Orientation | Resources for Infant Educarers |

| Waldorf | | |

Financial Assistance: Please check all types of financial assistance/subsidies offered at your program.

| Campership | Contracted Slots * | DCF Supportive Slots |

| Head Start | Private Scholarship | Sibling Discount |

| Sliding Fee Scale (private) | Teen Parent Slot | United Way |

| Vouchers | Other___________________ | |

* “Contracted” slots are slots that are subsidized by a contract with EEC to manage on a sliding scale fee dependent on income eligibility and a proven service need. They are NOT your regular slots and are managed by System Agencies.

Policies: Please check all that apply.

| Written Contract | Written Handbook | Provider Sick Allowance |

| Provider Vacation Allowance | Child Absence Allowance | |

Special Skills

Which of the following disability related services are available to children and their families in your program? Please check any that apply:

| Adaptive Equipment | Onsite Therapy | Onsite Medical Care |

| Onsite Nurse | | |

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Special Needs

Do you have experience working with children with disabilities/special needs? If yes, please check all that apply:

| Yes, I have experience | ADD/ADHD | Asthma/Allergies |

| At risk | Autism Spectrum Disorder | Behavioral special needs |

| Developmental special needs | Emotional/Social special needs | Feeding Tube |

| Hearing Impairment | Learning disabilities | Medical Condition |

| Monitors | Parental Incapacity | Physical special needs |

| Sensory Integration | Special Diet | Speech/Language |

| Visual Impairment | NO EXPERIENCE | Other |

Accreditation: Please check all that apply.

| NAFCC Accreditation, Expires: _____________________ |

| Other:___________________________________ |

Affiliations: Please check any that apply.

| Local FCC Association | Family Child Care System Agency | Religious |

| Hospital | College | Private School |

| Public School | CFCE | Other |

| Support Group Leader | | |

Do you use any of the following Child Assessment Tools? Please check all that apply:

| Ages & Stages | Creative Curriculum | High Scope Child |

| |Developmental Continuum |Observation Record |

| Work Sampling | Our Own Developed Assessment | Teaching Strategies Gold |

| Other:___________________________ | |

How often do you complete the above assessments?

| Annually | Twice a year | Quarterly |

| | | |

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Setting Please indicate the type of setting for your Family Child Care Home:

| House (single family) | Apartment | Townhouse |

| Mobile Home | Duplex | Non-Residential |

| Multi-family home | | |

Education

|Please check the highest level of education that you have achieved: |

| Degree related to health field | Degree related to special needs | LPN/RN |

| High School Education/GED | Degree related to ECE | Associate’s Degree |

| Bachelor’s Degree | Advanced Degree | CDA |

| Non-related degree | | |

Years of Experience

|Please indicate how many years of experience you have working in the Early Childhood Education field: |

| Under 1 Year | 1-3 Years | 4-9 Years |

| 10-20 Years | 21+ Years | |

Other Attributes

|Please check all that apply: |

| Assistant on call | Car used regularly | Dedicated indoor play area |

Census Bureau Statistics

|Please indicate your race/ethnicity (for statistical purposes only): |

| Spanish/Hispanic/Latino | White | Black or African American |

| American Indian or Alaska Native | Asian Indian | Native Hawaiian |

| Chinese | Filipino | Japanese |

| Vietnamese | Other:__________________________________________ |

Use this space to make any additional comments that will be useful for Information & Referral purposes:

_____________________________________________________________________________________

_____________________________________________________________________________________

Thank you for your time and cooperation!

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