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Contact Us:

18 North Norwood

Tulsa, OK  74115

 

918.834.2273

918.834.9339 (fax)

 

Office Hours:

8:30 am - 5:00 pm

Thursday till 8:00 pm

Saturdays

9:00 a.m.-2:00 p.m.

E-mail:  Info@ccrctulsa.org

 

CCRC is a program of the Community Service Council of Greater Tulsa

       

A funded program of the Tulsa Area United Way

 

 

 

And the Oklahoma Child Care Resource and Referral Association

 

CHILD CARE PROGRAM INFORMATION

Fill out all the information below to be listed with CCRC's database.

There is NO FEE to be listed. 

 

CCRC collects information from child care programs (and homes) for our database. If you are a licensed or exempt child care program, you may be listed with CCRC's database.  The information below helps parents find appropriate child care and helps local and state child care advocates gather information on child care in the area. 

 

 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)

Child Care Center Family Child Care Home  Large FCC Home
Pre-School/MDO Drop In Summer Camp
Before/After School Only   Nanny Head Start
First Start    

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):

Licensed Center Licensed Drop-In Licensed FCCH
Licensed Part Day Licensing Exempt  

 

Capacity:

Total Licensed Capacity:   Total Desired Capacity:   
Total Vacancies:

  

 

 

 

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)

Transportation Provided Walking Distance To School
Near Public Transportation Transportation to/from School
Transport to/from Home Close to School Bus Stop
Close to City Bus Stop  

 

Languages: (check all that are fluently spoken)

English ASL (Sign) French
Laotian Spanish Vietnamese
Arabic    

 

Current Star Level:

 

Accreditation:

 

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)

 

Day of Week Start Time (AM or PM) End Time (AM or PM)
Monday

Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

 

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:

 

Age of Child Weekly Part Time Weekly Full Time
Infant (0-12 months)    

Toddler (13-23 months) 

Toddler 2 (24-35 months)
Pre-School (36-47 months)
Preschool 2 (48-60 months)
School Age (61 + months)   

          

DHS Subsidy Clients:      

 

Age of Child Weekly Part Time Weekly Full Time
Infant (0-12 months)    

Toddler (13-23 months) 

Toddler 2 (24-35 months)
Pre-School (36-47 months)
Preschool 2 (48-60 months)
School Age (61 + months)   

                     

 

Population Information:

 

Age Group Desired Capacity Licensed Capacity Vacancies
Infant (0-12 months)   

Toddler (13-23 months)

Toddler 2 (24-35 months)
Pre-School (36-47 months)
Preschool 2 (48-60 months)
School Age (61 + months)

 

Program Attributes:       

 

Environment:  (check all that apply)

Indoor Pet No Pet
Outdoor Pet Smoke Free
Wheelchair Accessible  

 

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)

Administrators Credential Associate's Degree - Child Related
Associates Degree (not child related) Bachelor's - Child Related
Bachelor's - Non Child Related CDA/CCP Credential
CDA/CCP Currently Enrolled Certificate of Mastery
Master's & Up - Child Related Master's & Up - Non Child

 

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?

  

 

This section is for Family Child Care Homes Only

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

 

Type of Setting:

 

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?

 

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.  

Copyright © 2008  Child Care Resource Center. All rights reserved.
Revised: March 18, 2008.

 

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Last modified: June 03, 2008