Please check whether this is a:        NEW INTAKE            UPDATE

Today's Date: 

Contact Information: (Person Completing Intake)

First Name:     Last Name: 

Business Name: 

Type of Child Care Program: (check only one)

Location Address:

City:       Zip:     County:

Major Cross Streets:    and

Mailing Address (if different from Location Address):

City:       Zip:     County:

Contact Name (if different from above):    

Primary Phone:     Secondary Phone:

Fax Number:         E-mail address:

Website Address: 

LICENSE INFORMATION:

DHS License Number: K8  Expiration Date:

License Type: (check only one):

Capacity:

Accepted Age Range: (youngest to oldest)

        From:   Years   Months     Weeks

        To:        Years   Months     Weeks

Do you offer part-time care?    Yes        No

Do you offer drop-in care?      Yes        No

Schools Served (if any, list them all):

Funding:  (check only if you receive this type of funding)

      Head Start        State Pre-K Funding

Transportation: (check all that apply)

Languages: (check all that are fluently spoken)

Current Star Level:

One Star One Star Plus Two Star Three Star

Accreditation:

None NAEYC NAFCC NECPA ACSI NAC NSACA

Financial Assistance Offered: (check all that apply)

DHS Subsidy

Sliding Scale

SSI

Tribal (List Tribes): 

Days Child Care is Provided: (check the day of week and fill in times)

RATE INFORMATION:

(Note:  These rates are not quoted or publicized for parents, they are

primarily for statistical use and advocacy for early childhood programs)

Private Pay Clients:

DHS Subsidy Clients:      

Population Information:

Program Attributes:        For Profit Non Profit

Environment:  (check all that apply)

Meals:

Does your program participate in the USDA Food Program?

Yes - Please list the name of the program:

No

Special Needs:  (check any that apply)

Medical - Asthma, Allergies, Seizures, Apnea, Diabetes

Physical - Physical disabilities, Sensory Impaired (blind, deaf)

Developmental - Learning Disabled, Developmentally Delayed

Behavioral - ADD/ADHD, Autism, emotional/behavior issues

Education of Staff: (check any that apply to you or your staff)

Business Issues:  (check any that you offer)

Child Absence Rate

Contract with Parent

No Civil Rights Statement on File

Provider Sick Pay

Provider Vacation Pay

Unannounced Visits 

Program Features: (check any that apply)

Computers for children

Enrichment Classes

Field Trips - Drive  

Field Trips - Walk

Follows Curriculum

Montessori 

Religious Instruction

Small Group Sizes

Spanish Curriculum

Child Care Connector:

For web-based referrals, would you like to have your program information

available for parents when they use Child Care Connector?

Yes No   

This section is for Family Child Care Homes Only

If you operate a center, please skip to the next section.

Type of Setting:

House Apartment Townhouse Mobile Home Duplex Non-Residential

Please complete the following Census Bureau questions:

I choose not to answer the questions listed below.

Are you Spanish/Hispanic/Latino?

    No        Yes   Please specify: 

What is your Race?

Choose Not to Answer Caucasian African American American Indian/Alaskan Asian Indian Native Hawaiian Chinese Filipino Japanese Vietnamese Other Asian Guamaniana or chamorro Samoan Other Pacific Islander Other

Do you speak a language other than English at home?

    No        Yes  Please specify:

_____________________________________________________

This section is for all other child care programs:

I choose not to answer the questions listed below.

Please list the number of staff members who are:

  Mexican/Mexican American, Chicano

  Puerto Rican

  Cuban

  Other Spanish/Hispanic/Latino 

                (please specify)

Racial Background of Staff Members - please list the number of staff

who are:

Caucasian

African American

Asian Indian

Native Hawaiian

Guamanian/Chamorro

Samoan

American Indian/Alaskan  - Tribe:

Chinese

Filipino

Japanese

Vietnamese

Other Asian - List: 

Other Pacific Islander - List:

Other Race - List:  

Number of Persons on staff who speak a language other

than English at home:

What Languages?

 ______________________________________________________

Thank you for completing this form.  By clicking on the "Submit" button below, you certify that the information you have provided on this form is true and correct to the best of your knowledge.