Name

Program Name

Mailing Address

Phone Number

Email Address

1. Do you belong to a Family Childcare System?  Yes No

                If Yes, please provide the name of the System you belong to:

2. Do you offer a Nursery School Program (2 1/2hrs -3hrs a day)? Yes No

3. Do you offer full day care (6hours+ per day)? Yes No

4. Is your program available for care full year?  Yes No

5. Are you approved to accept any of the following types of childcare financial assistance funding (check all that apply):

                   Community Partnership Subsidies   Income Eligible Vouchers    Income Eligible Contracted Slots     DSS/DTA Contracted Slots

6. Are you licensed as a Large Family Childcare Program?   Yes No  

                If Yes, please indicate the number of assistants you employ: na 1 2 3 4  

7. Please indicate the number of children you have enrolled by age group:

          Infant/Toddler 0 1 2 3 4 5 6 7 8 9 10    Preschool 0 1 2 3 4 5 6 7 8 9 10    Kindergarten 0 1 2 3 4 5 6 7 8 9 10   School Age 0 1 2 3 4 5 6 7 8 9 10

8. Please indicate, by checking,  if you have any of the following EEC Certifications:   

   Teacher 

   Lead Teacher

   Director I 

   Director II

9. Please indicate, by checking,  if you have any of the following credentials, you may choose ALL that apply:   

   CDA, please indicate status: NA in process already attained CDA Credential 

   Associates Degree, please indicate status: NA in process already attained Assoc. Degree

   Bachelors Degree, please indicate status: NA in process already attained Bachelors Degree 

   Masters Degree, please indicate status: NA in process already attained Masters Degree

   NAFCC, please indicate status: NA in process already attained NAFCC Certification   

10. Do you currently utilize any of the following assessment tools in your program?  NO High/Scope Child Observation Record (COR) The Work Sampling System (WSS) Ages and Stages Questionnaire (ASQ) Creative Curriculum Developmental Continuum for Ages 3-5 Other

           If you chose Other in # 9, please provide us with the name of the assessment tool you use:

11. Are you/have you been involved with the UPK Grant through EEC?  No Currently Receiving Funding In Process of Applying Received Funding in the Past                                                          

12. Would you or your staff be interested in accessing career counseling services?  Yes No

13. Any additional comments, suggestions, ideas?