Parent referrals are dependent on the information you provide. Please answer each question as accurately as possible. If you have any questions please call NCFR at 1 (800) KIDS or (715) 634 2299.  By submitting this information you give NCFR permission to release your program name and information to families seeking child care and non-profit community agencies for educational opportunities.

General Information:
Name of Business
Phone    FAX
Contact Person    Title
Street Address
City    State    Zip
Municipality: City/Town/Township/Village of
Mailing Address (if different from above)
County    E-mail

Type of Child Care Program  (Check one)
Group Child Care        ( Profit    Non Profit )
Family Child Care    ( Licensed    Certified Provisional Certified )
Licensed Preschool
Head Start
Licensed Camp
Licensed School Age

Capacity and Enrollment Information
Please list the total capacity listed on your license or certification.

Rates are used for statistics only. They are NOT given to parents.

General Program Information
  (check one)
Age of the youngest child you are willing to care for      Weeks Months Years
                                                                                                                       
Age of the oldest child you are willing to care for           Weeks Months Years
                                                                                                                      

Transportation (check all that apply)
I am willing to transport children to/from daycare &/or school.
Transportation is the parents' responsibility.
The school bus is available for school pick up and drop off.
I do transport the children for field trips with the parents' permission slips on file.

Schedule Information  Please list the hours of operation for your program each day. Please begin at the earliest time child care is offered on each day. If preschool or school-age program, list all program times.
 

Type of Schedule
Full Time Care (child care 30hrs/week or more)
Part Time Care (child care less than 30hrs/week)

Special Schedule
Drop-In (temporary arrangements for 4 hrs or less/week)
Temporary/Emergency (unanticipated or temporary care dependent on vacancies)
Sick Care (children who are mildly ill)
24 Hour Care (must be regulated for a full 24 hour period)
Rotating Care (scheduled changes weekly)
Evening (care past 6:00 PM)(2nd shift)
Overnight (care between 11 PM and 7 AM) (3rd shift)
Before School (care a short time before school hours)
After School (care a short time after school hours)

Flexible
Please take time to carefully read and answer each section. For each section, mark all applicable categories. For example, if you will work with both part and full time schedules--mark both.

Flexible AM (willing to open 1/2 hour earlier than regular schedule within regulated hours)
Flexible PM (willing to close 1/2 hour earlier than regular schedule within regulated hours)

Year Schedule
Full Year (12 month care)
School Year (August - June)
Summer Only (June - August)

Meals Served
Breakfast
AM Snack
Lunch
PM Snack
Dinner

Program Environment (check all that apply)
Pool on the premises
NO Smoking on the premises (inside or outside the program)
NO Pets on the premises (inside or outside)
Enclosed play area on the premises
Wheelchair Accessible

Renewal Date on License/Certification

Date Established (year your program became regulated)

Financial Assistance
 In addition to enrolling children receiving the state's Child Care Subsidy, your program offers the following types of financial assistance for families. (check as many as apply)

Financial Assistance (i.e. sliding fee scale, scholarships)
Family Discount (discount for more than one child per family)  %discount
Other

Additional information about your child care business that should be included in your referral database record.

Provider Education
Family Child Care please check all that apply, Group Child Care Centers please check and enter the total number of staff that apply to each category.

Required FCC Certification Course
Required FCC Licensing Course
Fundamentals of Infant and Toddler Care
Infant/Child CPR (within two years)
Introduction to the Child Care Profession
Skills and Strategies for a Child Care Teacher
2 Year Degree (child related)
4 Year Degree (child related)
Masters Degree (child related)
CDA
First Aid (within two years)
RN/LPN
Administrator's Credential
School Age Credential
Infant/Toddler Credential
Special Needs Training (degree or extra training )
SIDS
Shaken Baby Syndrome Prevention

Special Needs Training/Experience
Caregivers have training or experience with the following (check as many as apply):
Emotional/Behavioral Disabilities (i.e. ADD/ADHD, Autism)
Physical Disabilities (Cerebral Palsy, Spina Bifida, Seizures)
Cognitive Disabilities (Down's Syndrome, Mental Retardation)
Sensory Disabilities (Hearing/Visual Impairment, Communication Disorder)
Health/Medical Disabilities (Allergies, Asthma, Diabetes, HIV/AIDS)
Feeding Tubes
Monitors
Special Diets
Giving Shots
Dispensing Medicine
No training or experience in any of these areas
Other

Statistical Information (Optional)
NCFR is seeking to respond to the diverse needs of families and providers and would like information on the ethnic backgrounds of child care professionals. Please enter the number of staff in your programs with the following ethnic backgrounds: