CHILD CARE PROVIDER INFORMATION FORM

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1 CHILD CARE PROVIDER INFORMATION FORM Please complete all available fields. We will use this information to refer parents to child care programs that meets their family's specific needs. By providing us with current, accurate information about your program, you are helping us to better serve parents and families throughout Lafayette Parish. Thanks for your cooperation & time! Program Name: Type of Care (choose 1) Physical Address: Child Care Center Family Child Care In-Home Child Care Preschool Program Head Start Early Head Start NSECD Other: Street City State Zip Mailing Address: Street City State Zip Director Name: Primary Phone: Fax Number: Secondary Phone: Date Program Opened: Website: LICENSING License # only if a licensed child care License/Registered Type: License Expiration: Type III Type II Type I Family Child Care Provider registered with CCAP Family Child Care Provider registered with the Food Program School/Class E Program NSECD Licensed Capacity: Desired Capacity: Total Vacancies: TIPS # CCAP with LDE TIPS Renewal Date: What is your program s quality rating? Is your program a non-profit? yes no 1 LPSS Success by 5 Alliance

2 AGE ACCEPTANCE Accepted Age Ranges: Include months and years TRANSPORTATION Transportation Offered: To/From Home To/From School Walking distance to school School bus drop off School bus pick up Is the Program located near a bus stop? yes no Is there an extra charge for transportation? yes no LIMITATIONS YES NO We only offer care to children of employees or students I only provide care for my grandchildren and am not interested in serving other children I only provide care for my own relatives and am not interested in serving other children Our program does not have limitations on who we serve Does your program accept children on a full-time and/or part-time basis? Full-time Part-time DAYS OF OPERATION Monday Tuesday Wednesday Thursday Friday Saturday Sunday EXTRA CARE SERVICES Does your program provide Drop-in Before School After School Rotating 24-Hour Open Holidays Respite Care Temporary or Emergency Care ENVIRONMENT Fenced Yard Gym No Pets Non-smoking Pool Outdoor Play Near Schools Near Public Transit MEALS PHILOSOPHY Breakfast Morning Snack Lunch Afternoon Snack Dinner USDA Food Program Special Meal Request Bring Own Food 2 LPSS Success by 5 Alliance

3 Developmentally appropriate practice Montessori Head Start Religious Reggio Emilia PITC FINANCIAL ASSISTANCE Child Care Assistance Program TANF Multi-child discount No Charge Scholarships Sliding Scale Other POLICIES Written Contract Written Handbook Provider sick allowance Provider Vacation Allowance EXTRA-CURRICULAR ACTIVITIES Field Trips Computers Tutoring Dance Gymnastics Kindermusik/Music English as a second language (ESL) Other HEALTH AND SAFETY CPR Current 2 year First Aid Training Health-related degree Liability Insurance Sick care Other SPECIAL NEEDS Speech, hearing or vision problems Other Physical disabilities Other medical conditions STAFF TRAINING Associate s Degree Bachelor s Degree Credit-Based Training Child Development Associate (CDA) Credential Career Ladder Staffing Plans NAC (National Administrator s Credential) PROFESSIONAL AFFILIATIONS Child Care Association of Louisiana (CCAL) Louisiana Early Childhood Association (LAECA)/SECA National Association for the Education of Young Children (NAEYC) National Association of Family Child Care (NAFCC) State Family Child Care Association Local Family Child Care Association National Child Care Association (NCCA) 3 LPSS Success by 5 Alliance

4 ACCREDITATION Please choose the type of accreditation your program has received. This does not mean that you are a member of the association, but that your program has gone through the formal accreditation process offered through the organizations. National Association for the Education of Young Children (NAEYC) National Association of Family Child Care (NAFCC) National Early Childhood Program Accreditation (NECPA) National Afterschool Association (NAA) National Child Care Association (NCCA) RATE INFORMATION Please specify if your rates are by the hour, day, week, month, or school year Part-Time Infant Care (0-12 months) Full-Time Infant Care (0-12 months) Part-Time Toddler Care (1-2 years) Full-Time Toddler Care (1-2 years) Part-Time Toddler 2 Care (2-3 years) Full-Time Toddler 2 Care (2-3 years) Part-Time Preschool Care (3-4 years) Full-Time Preschool Care (3-4 years) Part-Time Preschool Care (4-5 years) Full-Time Preschool Care (4-5 years) Part-Time School-Aged Care (5-10 years) Full-Time School-Aged Care (5-10 years) Part-Time School-Aged Care (11+) Full-Time School-Aged Care (11+) FEES Registration Fee Transportation Fee Field Trip Fee Supply Fee Other Fees 4 LPSS Success by 5 Alliance

5 FULL-TIME ENROLLMENT # Currently Enrolled # Current Vacancies Infants ages 0-12 months Infants ages 6 weeks-12 months Toddlers ages 1-2 years old Toddlers ages 2-3 years old Preschoolers ages 3-4 years old Preschoolers ages 4-5 years old School age children ages 5-10 years old School age children ages 11 years old PART-TIME ENROLLMENT # Currently Enrolled # Current Vacancies Infants ages 0-12 months Infants ages 6 weeks-12 months Toddlers ages 1-2 years old Toddlers ages 2-3 years old Preschoolers ages 3-4 years old Preschoolers ages 4-5 years old School age children ages 5-10 years old School age children ages 11 years old AUTHORIZATION (3 separate questions with required for each question) Do you give permission to LPSS Success by 5 to refer parents to your program through our phone based referral service? Do you give permission to LPSS Success by 5 to refer parents to your program via our online database? Do you give permission to LPSS Success by 5 to share information about your program s rates with parents and caregivers seeking child care referrals? YES NO This survey was completed by: Name Date 5 LPSS Success by 5 Alliance

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