Provider Application Form

Transcription

1 Provider Application Form : : City: ZIP: Phone #: Birthdate: Today s date: 1. Why would you like to be a member of Satellite Family Child Care? 2. How did you hear/learn about Satellite Family Child Care? 3. Are you currently providing Family Child Care in your home? yes no If yes, for how long? (Please attach a sheet listing the names, birthdates, and schedule of care for the children currently enrolled.) 4. Describe any training or experience that prepares you to do child care (e.g. classes you have taken, work experience ). U:\Erica\Provider Application\Word files\provider Application Form.doc 1

2 5. Please describe your child care environment (what rooms you use, how the environment is set up to meet the needs of the children you work with, etc.) 6. Briefly describe a typical day at your family child care home (include routines, activities). 7. Briefly describe your discipline/guidance practices how do you handle a conflict between children? 8. You will be required to have a current health exam and TB test. Do you have any health or medical concerns? U:\Erica\Provider Application\Word files\provider Application Form.doc 2

3 9. Is there anything else you would like us to know about you or your child care program? 10. Please list all children living in your home: Birth date 11. Please list all adult members of your household: Relationship Birth date Are you currently regulated to provide child care? Yes No Date of 4-C Certification: Date of State Child Care License: working on working on In the past twelve months, have you been found to be in violation of any State Licensing or 4-C Certification Standards? Yes No NA Have you ever been denied a State Family Child Care License or 4-C Certification? If yes, please explain. Yes No NA 13. Are you a U.S. citizen? Yes No If you are not a U.S. citizen, do you have a work permit? Yes No U:\Erica\Provider Application\Word files\provider Application Form.doc 3

4 14. The City of Madison has an ordinance requirement that Madison Accredited child care centers and homes may not exhibit religious bias in enrollment, instructional policies, practices or materials? Do you engage in religious teaching or practices when children are in care? Yes No If yes, please explain: 15. Present or most recent employer: : Dates of employment: Reason for leaving: 16. List three people who are not related to you who would be able to give a reference concerning your qualifications as a family day care provider. At least one of these people should have seen you caring for young children. All references will be verified. 17. Have you or any member of your household ever been convicted of any crimes, including physical or sexual abuse, or the neglect of children? If yes, please explain. Have all members of your household over 10 years of age completed a criminal background check (this is done through County Certification or State Licensing)? Yes No U:\Erica\Provider Application\Word files\provider Application Form.doc 4

5 Satellite Family Child Care does not discriminate in providing services on the basis of race, age, disability, gender, sexual orientation, religion, or national origin. The following questions are optional and will not be used to determine provider eligibility. They are for record-keeping purpose only. a) Please indicate your race: (i.e. Caucasian, African-American, Latino, etc.) b) Do you have handicapped status? Misrepresenting any information given in this application is grounds for denying or terminating Satellite Membership please complete all questions thoughtfully. I hereby certify that all the information given in this application is true to the best of my knowledge. Signature Date RETURN COMPLETED APPLICATION TO: Satellite Family Child Care 2096 Red Arrow Trail Madison, WI Attach your Enrollment Fee of $20 (payable to: DCPC Satellite) OR Complete and return the attached Request for Provider Fee Reduction form. If you meet the income eligibility guidelines, you do not need to pay the $20 enrollment fee. The Enrollment fee is refundable if Satellite is unable to offer membership. U:\Erica\Provider Application\Word files\provider Application Form.doc 5