a child care resource, referral & training agency

Family Child Care Provider

Monthly Update Form

To submit your information, please complete all fields, then click on the submit button below. If you would like to contact someone at Child Care Circuit about your submission please e-mail inquiries to: info@childcarecircuit.org. If you have any difficulty with this form please contact Corrine Corso at ccorso@childcarecircuit.org or at (978)722-2544.

Name of Provider:

Street Address:

City:

Zip:

Phone:

E-mail Address:

As of today, do you have any full time openings in your program?

	Yes
	No

How many full time openings? (Monday-Friday, full days)

Note: Total FT openings should not exceed your licensed capacity minus your current FT children in care unless you operate multiple child care shifts.

	For Ages:	Full time openings
	Infants
	15 months & up
	2 years and over
	Total full time openings

Do you have any part time openings in your program? (1/2 days, part week, Before school, After school).

	Yes
	No

	For Ages:	Part time openings
	Infants
	15 months & up
	2 years and over
	*School-age
*(if you have a Family Child Care Plus License)

What time do you open? What time do you close?

What are your full time rates? (Please indicate per week, per day, or per hour

Infants	per week	per hour	per day
15 months to 2 yrs	per week	per hour	per day
2 years + up	per week	per hour	per day
*School-age	per week	per hour	per day
*(if you have a Family Child Care Plus License)

What are your part time rates? (leave blank if you do not provide part time care)

Infants	per hour	per day
15 months to 2 yrs	per hour	per day
2 years + up	per hour	per day
*School-age	per hour	per day
*(if you have a Family Child Care Plus License)

What elementary school (s) are you near?

If any of the information listed below has changed since your last update, please indicate your new information.

Check the days you provide day care:

	Sunday
	Monday
	Tuesday
	Wednesday
	Thursday
	Friday
	Saturday

Do you offer a sibling discount for more than 1 family member enrolled in your program? Yes No

If yes, what is your sibling discount? (example: 10% off total, $25 off older child. These are examples, not recommendations)

Are your rates negotiable with parents? Yes No

Are you flexible with your hours? Yes No

What types of schedules are your willing to accept? (check as many as apply)

	Full time				Part time

	2nd Shift				3rd shift
	Rotating				24 hour care
	Before school				After school

	Drop in				Temporary
	Sick Care				Emergency

Are you closed in the summer? Yes No

Are you open school vacation week? Yes No

What ages of children do you enroll in your program? (Ex: 1 month to 12 years, 2 months) Note: If you just put 12 years, a parent searching for a child age 12 years and 1 month will not get your program as a referral.
From to years of age.

Do you have accreditation for the following: CDA NAFCC

If Yes:
Certificate expiration date:

Do you belong to a Family Child Care System? Yes No
If yes, name the system

Do you have a voucher agreement with Child Care Circuit? Yes No
(for more information on becoming a voucher provider, contact the Child Care Circuit at info@childcarecircuit.org)

Do you have outdoor play equipment (slide, swings, climbing structures, etc..)? Yes No

Highest level of Education obtained: (i.e. HS degree or BA in ECE, etc..)

If you do not have current openings in your program, please let us know what month you anticipate any, how many, and for what age.
Month(s) anticipated:

Child Care Circuit will now be doing all updates via e-mail:
To be updated, please include your email address:

Is there anything else you would like to share?

Thank you,

Corrine Corso, Manager of Customer Service