New Child Care Provider Information Form | Chatham County Partnership for Children

Thank you for answering the following questions so that we can provide accurate information to parents who call us for help finding child care. Child Care Search serves Chatham, Harnett, Johnston, Lee & Wayne Counties in North Carolina.

If you have any questions about this form, please contact Ronnie Jackson at ronnie@chathamkids.org or 919-542-7449 ext. 118.

Fieldset

Business Name *
Owner/Director Name (Primary Contact) *
Type of Facility *
Family Child Care HomeChild Care CenterChild Care Center in a ResidencePublic School Pre-KPreschool (Half-Day)School Age Care Program
May we give referrals to your facility? *
YesNo
May we give your RATES to interested families? *
YesNo
Street Address, City, State & Zip *
Mailing address (if different)
Primary Phone *
Secondary Phone
Fax Number
Email Address *
Website
Your preferred method of contact by us *
Best times to reach you by phone
License Type *
5 Star4 Star3 Star2 Star1 StarGS 110-106TemporaryProbationaryProvisionalMy facility is exempt from state licensure
Total Licensed Capacity *
Total Desired Capacity (if less than licensed capacity)
Youngest Age Accepted
6 weeks6 months1 year2 years3 yearsOther (specify below)
Youngest Age Acccepted, if "Other"
Oldest Age Accepted *
Schools You Pick Up From *
Please list ALL schools (including Head Start programs) you provide transportation from or are willing to provide transportation from. If none, type "none."
Schools With a Bus Stop *
Please list ALL schools (including Head Start programs) whose bus stops at your facility. If none, type "none."
Schools Withing Walking Distance
Please list ALL schools (including Head Start programs) that are within walking distance of your facility.
Does your facility offer these programs?
Early Head StartHead StartNC Pre-K
Is your facility near public transportation? *
YesNo
Do you provide transportation to and from home? *
YesNo
What languages does your staff speak? *
EnglishSpanishOther (please specify below)
Other language spoken by staff (if any)
Does your facility offer a school age summer camp program with field trips? *
YesNo
Which shifts do you operate? *
1st2nd3rd
Days of Operation *
MondayTuesdayWednesdayThursdayFridaySaturdaySunday
What are your operating hours? *For example: "7:00 am to 5:00 pm" or "M-Th 7:00 am to 6:00 pm and Saturday 7:00 am to 3:00 pm"
Are you willing to open earlier or close later if requested by a parent? *
YesNo
If yes, what hours would you be willing to open/close?
Do you enroll children part-time? *
YesNo
Please describe your part-time schedule. For example: "flexible, depends on the parent" or "parent must choose MWF or TuTh" or "pickup by 1:00 pm".
Do you offer any of these services?
Before school careAfter school careOvernight careRotating shifts careTemporary careDrop-in care
Are you open year-round? *
YesNo
If you are not open year round, what is your calendar?
Are you open on holidays? *
YesNo
If you are open on holidays, which ones?
Do you charge a registration fee?
YesNo
If yes, how much is your registration fee?
What are your rates? You can upload a file showing your rates if that is convenient.
What are your rates?
If you did not upload a file, please describe them below, listing part-time and full-time rates for each age group. Be sure to specify if the rates are per month or per week.
Do you charge any of these additional fees?
Late Pick Up FeeLate Payment FeeSupply FeeTransportation FeeOther Fee
Does your facility offer any of the following?
Computers for childrenFenced yardGym/Indoor gross motor spaceNo pets indoorsNo pets outdoorsPlayground equipmentPoolSmoke-free environmentWheelchair accessClassroom video observation in Director's officeClassroom video observation available to parents online
What meals do you serve? *
BreakfastMorning SnackLunchAfternoon snackDinnnerEvening snackNo meals served
Do you allow parents to provide food? *
YesNo
Will you accommodate special meal requests? *
YesNo
Do you participate in the USDA Child & Adult Care Food Program?
YesNo
Which types of financial assistance do you provide or accept? *
Check all that apply.Currently enrolled in state subsidy programNot enrolled in subsidy but willing to serve subsidy childrenNot interested in serving subsidy childrenMulti-child discountScholarship (provider-funded)Sliding fee scaleMilitary fee assistance program (NACCRRA)
What philosophy or philosophies does your facility follow? *
Developmentally appropriate practicesMontessoriReligiousReggio EmiliaPlay-basedOther
Do you provide any of the following specific services?
Staff with nursing certificateProvide diapersProvide wipesAccept cloth diapersAccept preschooler (age 3-4) not yet toilet trained
Does your staff have specific experience working with any of the special needs below?
We are NOT asking if you are willing to serve populations with specific needs. Instead, parents want to know if you have any EXPERIENCE or TRAINING related to the following needs.ADD/ADHDAllergiesAsthmaAutismCerebral PalsyChronic IllnessDevelopmental DelaysDiabetesDown SyndromeEmotional/Behavioral DisorderHIV PositiveHearing ImpairedIEP/IFSPInfant MonitorLearning DisabledMedical MonitoringMedically FragileMental DisabilityPhysical ImpairmentRespiratory EquipmentSpeech DelaySpeech/Language ImpairmentTube FeedingVision ImpairmentWheelchair/Mobility Impaired
Which of these describe your facility's affiliation? *
Single SiteLocal ChainState/Regional/National ChainReligious-sponsoredEmployer-sponsored
My child care location is: *
Residential (in my home)Church-based (in a church)Nonresidential (not in a home)Workplace-based (on-site at a business)
Is there anything else about your facility and the services you offer that you would like us to know?

Verification

Please enter any two digits *Example: 12
This box is for spam protection - <strong>please leave it blank</strong>: