1805 N. Dr. Martin Luther King Drive Milwaukee, WI 53212-3639 (414)562-2650 Fax: (414)562-2651
Please return form to:
4C 1805 N. Dr. Martin Luther King Drive Milwaukee, WI 53212 Fax # 414-562-2651
Date Completed: *
Completed by: *
General Information
Name: *
Title: *
Business Name:
Providing Care Since:
Type of Facility: * Group Child Care Center Family Child Care Home Preschool School Age
CCR&R will release your program name and information to families seeking child care by mail and thru on-line referrals unless you instruct us otherwise. If you do not want your name to be released at this time, please circle: "No" You may call at anytime to have your program included in the referral list. Please complete this form for statistical purposes.
Location Address: *
City: *
State: *
Zip: *
County: * City Village Town(ship) of:
Mailing Address (if different from above):
City:
State:
Zip:
Phone # 1: * Ext.
Phone # 2: Ext.
Fax:
E-mail:
Website:
Regulation Type *
State Licensed Group Center Country Certified Home State Licensed Preschool Program State Licensed School-Age Program (exclusively for school-age children) State Licensed Home Provisional Certified Home State Licensed Head Start Program State Licensed Camp
Ages of Children Served *
Age of the youngest child you are willing to care for: weeks months years(check one)
Age of the oldest child you are willing to care for: weeks months years(check one)
Children are transported to area schools by: (check all that apply) Transportation Provided Walking Distance to School Near Public Transportation
List all the schools transportation is provided to:
Language * Languages spoken by you or your staff (check as many as apply)
American Sign Language English Hmong Spanish Arabic Other (please list)
Program (check all that apply)
Planned activities provided:
Art Activities Large Muscle Activities Small Muscle Activities Story Time
Music Activities Walking Field Trips Driving field trips Science Activities
Indoor play-area Other Activities
Schedule Information *
Special Schedules:
Daytime Care (care that is provided before 6:00 pm)
Evening Care (care that is provided after 6:00 pm)
Overnight Care (care that starts after 10:00 pm & ends before 7:00 am)
Weekend Care (care that is provided on Saturday and/or Sunday)
Types of schedules/programs available (check as many of the following as apply)
Full Time Part Time Both
Full Year School Year Summer
Drop In (4 hours of care or less on a limited time basis)
Temporary or Emergency care
Before School Care
After School Care
Rotating (care changes from week to week)
24 hours (must be regulated for the full 24 hours)
Sick Care (children who are mildly ill or recuperating)
Open holidays (such as Thanksgiving, Christmas, etc.)
Scheduling Comments:
Rates
If you only serve children whose care is paid for by Wisconsin Shares and just accept the maximum county reimbursement rate check here
**School age rates for summer full week and vacation days put in Full-time rate and check week or full day. DO NOT put before and after school rates in full-time rate
0-12 months
1 years
2 years
3 years
4 years
5 years
**6-8 years
**9+ years
What is the minimum number of hours a child would need to attend to be charged your full time weekly rate?
Additional Fees(check as many of the following as apply)
Yearly Registration Fee One Time Enrollment Fee Security Deposit
Supply Fee Activity/Field Trip Fee Transportation Fee
Holding Fee Meal/Snack Fee Late Pick-up Fee
Ask Provider
Environment (check as many of the following as apply)
No dog/s on premises
No cat/s on the premises
No pets on the premises
Smoking is never allowed on the premises (inside or outside center/home)
Adult pool is on the premises
Outdoor enclosed play area
Building is wheelchair accessible
Meals
Breakfast AM Snack Infant Formula Provided PM Snack Dinner Parent Provide Lunch Evening Snack Food Program Participant N/A
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) :
No Financial Assistance
Sliding fee scale
Scholarships
Family discount (discount for more than one child per family)
Policies(Check as many of the following as apply)
Your program requires payment before care will be provided
Require parents to sign a contract
Payment is required when a child is absent
Maintain liability insurance
Have written policies or parent handbook
Willing to hold a spot for a fee
Child must be toilet trained before entering program
Have a substitute for sick/vacation days
Special Skills (place a check mark next to each of the following that you or your staff have COMPLETED)
Administrator’s Credential Preschool Credential Infant Toddler Credential
School-Age Credential Inclusion Family Service Credential
CDA (Child Development Associate)
RN/LPN/CAN (Registered Nurse/ Licensed Practical Nurse/ Certified Nursing Assistant)
Program Setting
Faith based (ex. in a church) Non-residential Workplace based or On-site
Special Needs Training/Experience Caregiver(s) have had training or experience with the following (check as many as apply)
Emotional/Behavioral Disability (i.e. ADD/ADHD, Autism) Training Experience
Physical Disability (Cerebral Palsy, Spina Bifida, Seizures) Training Experience
Cognitive Disability (Down’s Syndrome, Mental Delay) Training Experience
Sensory Disability (Hearing/Visual Impairment, Communication Disorder) Training Experience
Health/Medical Disability (Allergies, Asthma, Diabetes, HIV/AIDS) Training Experience
Feeding Tube Training Experience
Monitor Training Experience
Administer Shots
Provide Special Diet
No training or experience in any of these areas
*All providers have an obligation to reasonably accommodate children with disabilities in their programs
Training (place a check mark next to each of the following that you or your staff have COMPLETED)
Infant/Child CPR (class has been completed within the last 2 years)
First Aid (class has been completed within the last 2 years)
SIDS Training
Shaken Baby Syndrome
Child Abuse and Neglect
Wisconsin Model Early Learning Standards(WMELS)
Education (place a check mark next to each of the following that you or your staff have COMPLETED)
Required Licensing Courses (for family providers only) Required Certification Courses (for family providers only) Required Infant/Toddler Courses Required Course for Lead/Assistant Teacher (for group centers only) 1 Year Diploma (child related) 2 Year Degree (child related) 4 Year Degree (child related) Master Degree (child related) 2 Year Degree(non child related) 4 Year/Masters Degree (non child related)
Capacity and Enrollment Information
Group Centers please fill in the entire chart by age group.
Group Center Setting:
Faith-based
Non-residential
Workplace-based
Affiliation:
For Profit Employer Sponsored For Profit
Nonprofit Employer Sponsored Nonprofit
Government Sponsored Nonprofit
Preschool/Kindergarten Programs (check as many of the following as apply)
Provide a separate Preschool program on-site for 3 year olds Provide a separate Preschool program on-site for 4 year olds Provide 4-year old Kindergarten on-site with a DPI certified teacher Provide Kindergarten on-site with a DPI certified teacher
Number of persons on staff whose race is:
Wage & Benefits for Group Center Staff
**Directors Lowest Hourly Rate of Pay$ Highest Hourly Rate of Pay$
Benefits (Check all benefits currently offered to Directors)
Health Insurance Dental Insurance
Paid Family Leave Paid Holidays
Paid Vacation Days Paid Sick Days
Paid Preparation/Planning Time Paid Staff Meetings/In-services
Continuing Education Reimbursement Reduced Child Care Rates
**Assistant Directors Lowest Hourly Rate of Pay$ Highest Hourly Rate of Pay$
Benefits (Check all benefits currently offered to Assistant Directors)
**Teachers Lowest Hourly Rate of Pay$ Highest Hourly Rate of Pay$
Benefits (Check all benefits currently offered to Teachers)
**Assistant Teachers Lowest Hourly Rate of Pay$ Highest Hourly Rate of Pay$
Benefits (Check all benefits currently offered to Assistant Teachers)
Enrollment Information
Family Home Setting
House Mobile Home Apartment
Duplex Townhouse Non-residential
Family Provider Benefits (Check all that apply)
Paid Vacation Days Paid Sick Days Health Insurance
Family Wage Information
Wages (A report will be compiled and sent to all providers who answer this question)
What was your taxable income from 20XX Federal Tax Return Form 1040, Schedule C, Line 31$ (This is just the income for the family provider services, not the overall family income)
Census Bureau Questions (Optional, for statistical purposes only)
What is your race?
YOUR PRIVACY RIGHTS
Our mission is to provide parents with objective information about child care programs in their community and information on selecting quality child care. CCR&R does not endorse or recommend any particular child care program. Parents are strongly encouraged to visit each site and ask questions about policies and procedures of the program before making a final decision. We will not guarantee that you will receive prospective parents from CCR&R. We encourage you to continue to advertise through local newspapers, church and other organizations. We ask that you notify CCR&R of any vacancies or changes in your program (hours of operation, phone number, address, etc.)
The purpose of collecting the information in this form is to:
You are not required to provide this information, but without it, we will not be able to help parents locate your program. In addition, the information is used for statistical reporting that influences planning, policy development, and funding levels. Statistical information never includes provider names, and may be shared with community groups, etc. At times, we receive requests for a mailing list of providers from outside sources that have a legitimate provider interest, such as a public health alert, etc. This information (name, address) is public information. Other information about your program is not provided to outside vendors.
This notice covers all changes you make in your file (by phone, in person, or written) until your file is deleted from the database. I authorize the information in this form to be used as outlined above.
Signature:
Date:
(These are questions that all agencies do not have to ask. If your agency would like to ask these or any other questions, feel free to do so and insert them into the appropriate place on the BIF Form.)
Contact information:
Closest cross street [intersection] to your program:
Municipality: City Village Town(ship) of:
Languages: The six options that are above are required. Agencies may decide to add more to customize this form for this for their service delivery area.
Schools Served
School District your program is located in: Elementary School(s) [public and parochial] your address is assigned to Elementary School(s) [public and parochial] closest to your program
Types of schedules/programs available: Provides part-time care for infants
Additional Fees Asking the rates for additional fees is optional for your agency. You still need to ask if there are additional fees being charged and also the regular child care rates (the chart).
Provider Professional Statement (optional) This is your opportunity to share information about your program. This statement will be printed on your profile for parents who contact XXXX to receive a child care referral listing. Please print clearly as this statement will be printed exactly as it appears. We will not be able to print this information if we are unable to read the statement. (Please be concise. Maximum of 75 words allowed).
Group Center Add a column on the chart asking for the number of rooms for each age group. Add a column to the chart asking for group size.
(Please note that all of the columns in this section of NACCRRA are taken up so this information would need to be tracked outside of NACCRRA or somehow in a local agency field.)
Rate Information – Nursery/Preschools Only
Number of days child(ren) allowed per year without pay? Sick Days: Vacation Days: Personal Days: There is not a clear/easy way to track this in NACCRRA
