4C GROUP CHILD CARE PROGRAM BUSINESS INFORMATON FORM

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

First Name:

Last Name:

Business Name:

CARES ID Number:

4C will give your program name and information to families seeking child care unless you instruct us otherwise.
If you do not want your name to be given to families at this time, please call 414-562-2676.
You may call at anytime to have your program included in the referral list.

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      I care for relatives ONLY      
County Certified Home      Provisional Certified Home

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)

List your total vacancies at this time:

TRANSPORTATION

Does your program provide transportation?      YES     NO

Do you provide transportation to or from a child’s home?      YES     NO

Children are transported to area schools by: (check all that apply)
School Bus      Program Van/Car      Children walk 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)

Provides part-time care for infants      Provides Respite care     
Child must be toilet trained before entering program     

Schedule Information *

Types of schedules/programs available (check as many of the following as apply).

Full Time      Part Time      Both       Drop In (care on a limited time basis)      Full Year
School Year      Summer       Temporary/Emergency      Before School (not including kindergarten)      After School (not including kindergarten)      Rotating (care changes from week to week)
24 hours (must be regulated for the full 24 hours)      Open Holidays (such as Thanksgiving, Christmas)
Sick Care (children who are mildly ill or recuperating)
2nd Shift (care occurs during most of the hours between 2 pm and 12am, with the majority of the hours after 6 pm)
3rd Shift (care occurs during most of the hours between 10 pm and 7am, with the majority of the hours after 12 am)

Scheduling Comments:

Rates (You may also include your program’s rate sheet.)

Additional Fees

Activity Fee      Holding Fee       Late Pick-up Fee      Meal/Snack Fee     
One Time Enrollment Fee      Security Deposit      Supply Fee      Transportation Fee     
Yearly Registration Fee

Environment

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      Home is wheelchair accessible

Meals

Breakfast      Afternoon Snack      Infant Formula Provided      Morning Snack      Dinner     
Parent Supplies Meals      Lunch      Evening Snack     

Is your program a member of a Child Care Food Program?     YES     NO

4C Food program      Silver Spring Food Program      WECA Food Program     

Program Philosophy

Montessori      Waldorf      High Scope      Religious based

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)

No other financial assistance is offered

Policies

Keeps Waiting List      Maintain liability insurance      Provider Sick allowance     
Provider Vacation allowance      Require parents to sign a contract     
Have written policies or parent handbook      Require payment when child is absent

Number of days child(ren) allowed per year without pay?
Sick Days:       Vacation Days:      Other:

Special Needs Training/Experience
Caregiver(s) have had training or experience with the following (check as many as apply)

Emotional/Behavioral Disability Training (i.e. ADD/ADHD, Autism)

Emotional/Behavioral Disability Experience (i.e. ADD/ADHD, Autism)

Physical Disability Training (Cerebral Palsy, Spina Bifida, Seizures)

Physical Disability Experience (Cerebral Palsy, Spina Bifida, Seizures)

Cognitive Disability Training (Down’s Syndrome, Mental Retardation)

Cognitive Disability Experience (Down’s Syndrome, Mental Retardation)

Sensory Disability Training (Hearing/Visual Impairment, Communication Disorder)

Sensory Disability Experience (Hearing/Visual Impairment, Communication Disorder)

Health/Medical Disability Training (Allergies, Asthma, Diabetes, HIV/AIDS)

Health/Medical Disability Experience (Allergies, Asthma, Diabetes, HIV/AIDS)

Feeding Tube Training

Feeding Tube Experience

Monitor Training

Monitor 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

Education (place a check mark next to each of the following that you or your staff have COMPLETED)

Required Infant/Toddler Course                2 Year Degree (child related)
Required Course for Assistant Teacher    4 Year Degree (child related)
Required Course for Lead Teacher          Master Degree (child related)

Special Skills & Credentials (place a check mark next to each of the following that you or your staff have COMPLETED)

Administrator’s Professional Credential
School-Age Professional Credential      Infant Toddler Professional Credential
CDA      RN/LPN/CNA

Family Home Setting

House      Mobile Home      Apartment      Duplex       Townhouse       Non-residential

Family Provider Benefits

Paid Vacation Days      Paid Sick Days      Health Insurance

Census Bureau Questions (Optional, for statistical purposes only)

Are you Spanish / Hispanic / Latino?
No, not Spanish / Hispanic / Latino      Yes, Mexican, Mexican American, Chicano       Puerto Rican      Yes, Cuban      Yes, other (print group)

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:

1. Effectively provide referrals to parents who are looking for child care and provide appropriate program information.
2. Report and gather statistics on child care needs.
3. Provide training and technical assistance to meet your needs as a child care provider.

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: