SKCDC - Southern Kennebec Child Development Corporation

Provider ID	First Name		Last Name
Business Name
Type of Care
Date first provided care		Status: ActiveInactive
Would you like referrals from Child Care Options? Yes No
Would you like your rates printed? Yes No Web Referrals? Yes No

Contact:

Primary Phone		Secondary Phone		Fax:
Email			Website address

License Information:

License type (Licensed/Certified/Legal Exempt)
EIN/SSN #		License ID#
Expiration date

License Type:

4 children, 1 adult	5 children, 1 adult	6 children, 1 adult
8 children, 1 adult	10 children, 1 adult	12 children, 2 adults
12 children, 1 adult	2 children, 1 adult

Capacity and Accepted Age Range:

Total licensed cap.		From yearsmonths weeks
Total desired cap.		From yearsmonths weeks
Total vacancies	as of	Number of shifts/session

Catchement Area/School Information:

Please list the schools which are on your bus route:

Other:

Funding:

Head Start funding?

State Pre-K funding?

Transportation:

Transportation provided

Within walking distance
from school

Access to public transportation

Languages Spoken (please list):

Vacancies:

Infant	Infant/Toddler	Toddler
Preschool	Kindergarten	School age
Part time	Evening	Overnight
Full time	Weekend care

Special Needs Data (number of special needs children you currently care for):

1-2

3-5

6 or more

Day Care Provided:

Day	Start Time	End Time
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Accepts Children:

Full time	Part time	Both	Full year	Summer only
Schol year only	Drop in	Temp/emergency	Before school	After school
Rotating	24 hour	Open holidays

Rates:

Age Group (Age Range)	Hourly, PT	Hourly, FT	Daily, PT	Daily, FT	Weekly, PT	Weekly, FT	Monthly, PT	Monthly, FT	Other, PT	Other, FT
Infant 1 (6 wks - 12 months)
Infant 2
Toddler 1 (13 months - 2 1/2 years)
Toddler 2
Preschool 1 (2 1/2 - 5 yrs)
Preschool 2 (Nursery school)
School Age 1 (1st grade - 5th grade)
School Age 2 (kindergarten)

Additional Fees:

Field trip/special activity	Late fee	Lesson	Annual registration fee
Preschool fee	One time registration	Drop in	Other

Population Information:

Age Group (Age Range)	Des Cap	Lic Cap	Sub Cap	FT Vac	PT Vac	Vac Date	Monthly, PT	Enroll	CA Ratio	Grp Size
Infant 1 (6 wks - 12 months)
Infant 2
Toddler 1 (13 months - 2 1/2 years)
Toddler 2
Preschool 1 (2 1/2 - 5 yrs)
Preschool 2 (Nursery school)
School Age 1 (1st grade - 5th grade)
School Age 2 (kindergarten)

Attributes:

Provides respite care?

Not for profit?

Environment:

Outdoor play	Pool	No pets
Near public transportation	Lead safe	Non smoking
Pets	Fenced yard	School bus route
Preschool program	No indoor pets	Cats
Dogs	Caged pets	Transportation provided
Faith based

Meals:

Breakfast	Morning snack	Lunch
Afternoon snack	Formula	Dinner
USDA food program	Special diet	Parent provides meals

Philosophy:

Child centered	Montessori	Waldorf
Reggio Emilia	High Scope

Financial Assistance Accepted:

Aspire	Voucher/transitional	Contracted slots
Home Start (Head Start)

Policies:

Written contract	Written handbook	Multi-child discount
Provider takes paid vacations	Provider vacations are unpaid	Parents pay when they take their vacation
Paid holidays	Family vacation allowance	Child absence allowance

Safety:

CPR/First aid training	Health-related degree	On-site nurse
Liability insurance	Audio monitor	Video camera - view childs classroom over Internet
Password/passkey admittance	Sids monitors	Video camera - view child within home/center

Special Needs Experience:

Speech & Language	Hearing	Multiple Disabilities
Physical disabilities	Developmental Delays	Social/Emotional
Asthma	ADD/ADHD	Diabetes
Vision	Food allergies	Seizures other than Febrile
Tube feeding	HIV/Hepatitis B	Training/education
Experience	Wheelchair accessible	Willing to be trained
Autism/Pervasive developmental disorder	Sensory	Cleft lip/palate
Inclusive child care core knowledge training MRTQ	Cerebral Palsy	Social emotional core knowledge training MRTQ

Training:

6 hours of workshops and training	7-12 hours of workshops and training	More than 12 hours of workshops and training
13-40 hours of workshops and training	More than 40 hours of workshops and training	College courses for credit
MRTQ training

Experience:

Under 1 year experience	1-3 years experience	4-9 years experience
10-20 years experience	21+ years experience	Family child care experience
Child care center experience	Nanny experience	Elementary school

Education:

High school education	Some college, child related	Some college, other emphasis
Associate degree, child related	Associate degree, other	Bachelor's, child related
Bachelor's, other	CDA	Masters, child related
Maine Road to Quality registry

Accreditation:

NAFCC	NAEYC	NSACCA
In process

Affiliation:

NAFCC	NAEYC	Maine FCC Association
Local FCC Association	Maine Child Care Directors Association	College
Religious	Family Network	YMCA/YWCA

Quality Indicators:

Quality Certificate?

Yes

No

Flexible Schedule?:

Weekend care	Overnight care	Mornings only
Afternoons only	Evening care	Operation Child Care

Activities Offered:

Religious	Music and movement	Arts and crafts
Cooking	Story time	Preschool curriculum
Field trips	Circle time	Offers lessons
Cultural activities

Ethnicity (Race - Optional):

Black/African American	Asian	Hispanic/Latino
White	Native American/Alaskan	Hawaiian/Pacific Islander

Best Time to Call?:

Call during nap	Call morning	Call in evening
Weekends	Send e-mail update request	Afternoons
Anytime

Special Services:

Offers mildly-ill child care	CDS Contract	Open snow days
Open school vacations	Back-up care	Other
Summer camp program	Co-op

Paid Holidays Per Year?:

4	5	6	7
8	9	10	11
12	Will discuss

Family Child Care Setting:

House	Apartment	Town house	Mobile home
Duplex	Non-residential
Wages: /year

Benefits:

Own health insurance	Spouse health insurance	Own dental
Spouse dental	Retirement	Paid sick
Paid vacation

Center Information Only* (Check all that apply):

Residential	Volunteers	Family style meals
Non-residential	Parent advisory	Sliding Scale
Faith-based	More than 3 sites	Parent cooperative
Work place based	Intergenerational	Scholarships (available to paraents)

Signature of provider:

______________________________Date_______________

Provider Application

General Information: