ChildCareGroup | Resource & Referral: Registration / Schedule

Your role as a provider is not the same as a parent, but children do feel loved and protected in your care.


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Register Your Facility or update your information:

If you are a Registered or Licensed Child Care Provider, you may register your facility or update your information with Resource and Referral by filling out the online Child Care Provider Form by clicking here.

If you prefer, you may download the form by clicking here and once completed, send it to us via:

Fax:	214-631-1943 or
Mail:	ChildCareGroup Resource and Referral Program 8585 North Stemmons Freeway, Suite 500 South Dallas, TX 75247

Child Care Provider Data Sheet

Contact/Director's Name:
Business Name:

Type of Care (please choose one):

Child Care Center
Licensed Child Care Home
School-Age Program
Pre-Kindergarten
Private School

Registered Child Care Home
Part-Time Program
Camp
Head Start
Nanny Agency

Street Address:
City:
County:
ZIP Code:	- (+4)

Mailing Address:
City:
County:
ZIP Code:	- (+4)

Primary Phone Number:
Secondary Phone Number:
Fax Number:
Email address:
Web site:
License ID:
EIN/SSN:

Center Capacity
Total Licensed Capacity:
Total Desired Capacity:
Current vacancies for what ages?:

Ages Served:
From	Years	Months	Weeks
To	Years	Months	Weeks

School Districts Served:

Schools Served:

School Transportation Provided:
To School	From School Pickup	Not Provided

Languages Spoken:
English	Spanish	American Sign
Other:

Subsidies Accepted:
CCA	Head Start	Sliding Scale
Sibling Discount	Scholarships	Voucher Programs
Corporate Discount	Early Intervention	United Way
Other:

Program Type:
Parent’s Day Out	Parent Co-op	Montessori
Mildly Ill care	Back-up care	Training/Lab School
Special Needs only

Schedule:	Start Time	End Time
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Care Available:
Full-Time	Part-Time	Both

Duration of Service:
All Year	Summer Only	Drop-In
Before School	After School	Rotating
Open Holidays	Temp./Emergency	24-Hour Care

Fees Charged:

Age Group	Age Range	Rate	Monthly	Daily	Weekly	Hourly
Infant	0-11 months
Infant	12-17 months
Toddler	18-23 months
Toddler	2 years
Preschool	3 years
Preschool	4 years
Kindergarten	5-6 years
School Age	6 years and up

At what age does part-time begin?
Fees:
Schedule:
Registration Fee:

(Choose one:) Annually or One-time only
(Choose one:) Per Child or Per Family
Other Fees:

Capacity:

Age Range	Desired Capacity	Licensed Capacity	Group Size	Child/Adult Ratio
0-11 months
12-17 months
18-23 months
2 years
3 years
4 years
Kindergarten
School Age

Environment (check all that apply):
Smoke free	Indoor Play Area	Outdoor Play Area
Pool On-site	No Pets	Outdoor Pets
Indoor Pets	Secure Entry	Internet Viewing
Video Monitoring

Meals (check all that apply):
Breakfast	Morning Snack	Lunch
Afternoon Snack	Dinner	USDA Food Program
Special Meal Request	Parent Provides Lunch
	Meals offered at additional fee

Philosophy:
Montessori	Waldorf	RIE
Faith Based	Abeka

Policies (check all that apply):
Written Contract	Written Handbook
Multi-Child Discount	Provider Sick Allowance
Provider Vacation Allowance	Child Absence Allowance
Dispense Medications	Smaller Child/Staff Ratio
Provide References

Safety:
CPR Current within 2 years	First Aid Training
Health-Related Degree	On-Site Nurse
Liability Insurance

Special Needs (check all that you have had experience with):
Mentally Delayed	Physically Delayed
Emotional/Behavioral Disorder	ADHD/ADD
Hearing/Visual Impairment	Developmentally Delayed
Mobility Impairment	Learning Disability
Medically Fragile	Speech Delay
Tube Feeding	Asthma/Allergies
Medical Monitor	Autism
Cerebral Palsy	Seizures
Chronic Illness	Multiple Disabilities

Training Required of Staff:
Less than 12 hours of In-service	13-40 Hours In-service
Above Minimum Standards

Experience:
Under 1 year	1-3 years
4-9 years	10-20 years
21+ years	Family Child Care Experience
Child Care Center Experience

Education:
High School Education	Some College, Child Related
Some College, Other Emphasis
Associate Degree, Child Related
Associate Degree, Other Emphasis
Bachelor’s Degree, Child Related
Bachelor’s Degree, Other Emphasis
Master’s/PhD	CDA
Degreed Director

Accreditation:
NAEYC	NAFCC
NSACCA	AMSA

Member of:
NAEYC	TAEYC
NAFCC	TAFCC
Local Association

Are your a Texas Rising Star Program?
Yes No

Special Services:
Mildly Ill Care	Substitute Plan
School Holidays/Summer Program	Occasional Evenings/ Overnight
Occasional Weekends	Social/Health Services
Military Care	Diapers Provided
Open Some Holidays	Inclusion

Transportation:
Near Public Transportation	School Transportation
Home Transportation	Field Trip Transportation
Sometimes Transports in Car	No Transportation

Camp Type:
Academic	Art
Computer	Parks & Recreation
Special Needs Focus	Sports
Youth Program	Faith Based
Other

Staffing Information: Info on staff positions, salary range, benefits (specify below)

Staff Title	Highest Pay	Lowest Pay	Benefits Available

Name and Title of Staff Completing Form:

For Future Phone Contact:
Best Person to Contact:

Phone Number:

Best Time of Day to Call:

Thank you for taking the time to complete this form.
Press the "Submit" button below when finished.