Collaborative for Children

PROVIDER UPDATE FORM

Please use this form to update your facility information so that we keep current information in our child care database.

Provider Information

Center Director/Owner Name
Child Care Center Name
Physical Address
City		Zip Code
Mailing Address
City		Zip Code
Primary Phone No.		Secondary Phone No.
Fax No.		Email Address
Website
License/Registered ID
ACCEPTED AGE RANGE		Weeks
From: Years	Months
To: Years	Months	Weeks
DAYS/HOURS OF SERVICE
DAYS	START TIME	END TIME
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Accepts Children:
Full Time	Part Time	Both

Duration of Service
All Year	School Year Only	Summer Only

Please complete all rows that apply:
Fee Charged for Full Time Care (25+ hours per week)
AGE GROUP	AGE RANGE	RATE	PLEASE SELECT ONE
Infants	0-11 months
Infants	12-17 months
Toddler	18-24 months
Toddler	2 years
Preschool	3 years
Preschool	4-5 years
Before School	6-12 years
After School	6-12 years
Before & After School	6-12 years
Summer School	13-17 years

Please complete all rows that apply:
Fee Charged for Part Time Care (less than 25 hours per week)
AGE GROUP	AGE RANGE	RATE	PLEASE SELECT ONE
Infants	0-17 months
Toddler	18-24 months
Toddler	2 years
Preschool	3 years
Preschool	4-5 years
School Age	6-12 years
School Age	13-19 years

Registration Fee:	$	This amount is:
Please Choose One: Collaborative for Children has permission to give my fees to families Collaborative for Children does not have permission to give my fees to families
Total Licensed Capacity
Please complete all rows that apply:
Capacity
AGE RANGE	NUMBER OF CLASSROOMS	DESIRED CAPACITY PER AGE GROUP	GROUP SIZE PER CLASSROOM
Infants 0-11 mos.
Infants 12-17 mos.
Toddler 18-24 mos.
Toddler 2 yrs.
Preschool 3 yrs.
Preschool 4-5 yrs.
School Age 6-12 yrs.
School Age 13-17 yrs.
If certain age groups are combined in one classroom, please explain:

Please check all that apply to your program:
Services Your Program Provides
Drop In Care Temp/Emergency Care Before School Care After School Care
Rotating Shifts 24 Hour Care Open for Holidays

Please check all that apply to your program:
Subsidy
Silding Scale Scholarships Federal Assistance (CCDF) Head Start Pre-K
Corporate Discounts United Way Military

Please check all that apply to your program:
Languages Spoken by Staff in Your Program
English Spanish American Sign-Language French Russian
Japanese Chinese Vietnamese German Cambodian
Somalian Taiwanese Korean Arabic Other

Please check all that apply to your program:
Transportation Provided
Near Public Transportation Transports to School Transports to Home
Transportation Service Transports for Field Trips Transports in AM
Transports in PM Provide 1/2 Day Transportation Sometimes Take in Car
No Transportation

List All School Districts Served 1. 2. 3. 4. 5. 6.
Elementary Schools Your Center Transports to and/or From 1. 2. 3. 4. 5. 6. 7. 8. 9.

Please check one:
Care Setting
Non-Residential Faith Based Work Place Based Residential School Based

Please check one:
Business Status
Non-Profit Chain Independent For Profit

Staffing Information
STAFF TITLE	# EMPLOYED	AVERAGE LENGTH OF TIME EMPLOYED
Director
Assistant Director
Program Coordinators
Lead Teachers
Teachers
Teacher Assistants/ Floaters
Office Staff
Nurse
Cook
Driver

STAFF TRAINING/EDUCATION of LEAD TEACHERS in EACH CLASSROOM
AGE RANGE	YEARS OF EC EXPERIENCE	LIST EDUCATION/ CERTIFICATIONS or DEGREES HELD
0-11 months
12-17 months
18-24 months
2 years
3 years
4-5 years
6-12 years
13-19 years

STAFF BENEFITS Please check all that apply to your staff:
Benefits
Health Insurance Paid Vacation Professional Development
Paid Sick Leave Paid Training Discount on Child Care
Training Incentives Other

Accreditation
NAEYC NAFCC NAA NECPA AMSA AMIA NAC


Affiliation
NAEYC NAFCC TASAC NASAC Local AEYC AMI/AMS

Quality Level-Subsidy Program
Texas Rising Star 4 Texas Rising Star 3 Texas Rising Star 2 Degreed Staff Smaller Child/Staff Ratio
Parent Involvement (check all that apply)
Parent Meetings Family Friendly Policies Parent Advisory Boards Parent Education/Workshop for Parents Host Family Events Newsletter Professional Development (check all that apply) Seek and participate in early care and education training opportunities Staff enrolled in continuing education classes/child development credential classes All appropriate staff complete 15+ hours of child development training per year

PROVIDER UPDATE FORM

STAFF TRAINING/EDUCATION of LEAD TEACHERS in EACH CLASSROOM