Child Care Resources of Rockland, Inc. / For Parents & Families

Additional Services

Child & Adult Care Food Program

Compliance Information

Eat Well, Play Hard

Infant Toddler Regional Resource Center

Media Project

Professional Development

Provider Intake Form

Quality Child Care Campaign

Resource Links

Scholarship Information

Provider Intake Form

* Provider Name

Provider Program

* Address

* City

* State

* Zip

* Telephone #

Secondary Phone #

Fax #

Email Address

School District

Elementary School(s) Please list schools that you are on the bus route for

Type of Care (Please check only one)

Total Licensed Capacity

Total Desired Capacity

* Total Vacancies

Language(s) spoken

Is your program located near public transportation?

Yes No

Do you provide transportation?

Yes
No

Medication – MAT?

Does your program include?

Pre-K
Kindergarten
Summer Program
School
Summer Program Age

Nursery School Program
Play Group
Camp
Special Education
Special Interest

Environment - Please check all that apply to your program.

Smoke-Free
Smoking
Pets
No Pets
Fenced Pool
Fireplace

Wood Stove
Outdoor Play Area
Fenced Yard
Computer
Gym

Meals - Please check all that apply to your program.

Breakfast
Morning Snack
Lunch
Afternoon Snack

Dinner
Kosher
Parents Provide Meals
CACFP

Philosophy - Please check all that apply to your program.

Academic
Mixed Age
Child Development
Montessori

Parent Involvement
High Scope
Faith-based/Religious Curriculum
Waldorf

Financial Assistance

Voucher/Subsidy
County Contract
Multi-Child Discount
Sliding Fee Scale

Fee Negotiable
Scholarship
United Way Scholarship/Discount

Policies

Written Contract
Written Workbook
Provider Sick Allowance
Provider Vacation Allowance

Child Absence Allowance
Liabililty/Accident Insurance
Will Supply Social Security Number
Medical Form on Each Child

Are you a LAP (Love, Acceptance, Patience) Provider?

Yes No

Safety

Current CPR
Current Infant/Toddler

First Aid Training
On-Site Nurse

Special Needs

Developmental Disability
Educational Disability
Special Care Needs
Wheel Chair Access
Special Diet
Sign Language
Moderately Ill
Transportation

Inclusive/Integrated
Itinerant
Gifted
Other

If you are familiar with a particular special need, please specify here:

Training

Business Management
Child Abuse
Child Development
Discipline
ECE Training
Health/Safety

Leadership Management
Nutrition
Medication Training (MAT)
Orientation
Advanced Training

Experience

Under 1 Year Experience
1-3 Years Experience
4-9 Years Experience
10-21 Years Experience

21+ Years Experience
Family Child Care Experience
Child Care Center Experience

Education

High School Education
ECE/Child Related Degree
Other Emphasis Degree
Special Education Degree
Associate's Degree

Bachelor's Degree
Master's Degree
RN/LPN
Health Related Degree

Accreditation

NAFCC
NAA

NAEYC

Affiliation

College Operated
Independent Proprietary
Public School
Employer Affiliated/Managed

Faith-based/Religious
Health/Safety
Goer Site
Proprietary Franchise

Additional Care Services

Full Time
Part Time
Full Week
Part Week
Full Day
Part Day
Evening
Flexible Hours

Overnight
Snow Days
Morning
Afternoon
Weekend
Extended Hours
Mildly Ill/Sick

CDA

Center
Family Child Care

Infant-Toddler
School-Age

Schedule

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

Fee Schedule

Age Group	Age Range	$ Rate per Week
Infant	6 weeks-23 months
Toddler	24 months-35 months
Preschool (1)	3-4 years
Preschool (2)	4-6 years
School-Age (1)	5-10 years
School-Age (2)	10-12 years