Use this form to update all of your information, recommended at least once a year. If you provide child care in Kent County, please take a few minutes to fill out this form. This form replaces the full file update performed at least annually and will prevent you from receiving a phone call by Kent Regional 4C staff to obtain this information. If you have filled out this form within the last year, and need to make additional changes or update your vacancies, please use the Vacancy Update Form. Use the tab key to move through the form.

---

Family/Group Home Inital and Yearly Update Form Center/Preschool/School-Age Inital and Yearly Update Form

---

BASIC INFORMATION

Today's date
First Name
Last Name
Name of business
Address
City
State
Zip code
County
Daytime telephone (with area code)
Other telephone (with area code)
Fax number (with area code)
E-mail address
Web URL (if applicable)

Closest intersection to your home

---

DEMOGRAPHIC INFORMATION
The following demographic information is collected exclusively for our funding purposes
as required by the United Way. The following questions are optional and kept confidential:

Gender
Male
Female

Age
15-19 years20-29 years30-39 years
40-49 years50-59 years60-69 years
70-79 years80+


Ethnic Origin/Race
Asian/Pacific IslanderCaucasianNative American
African AmericanHispanicOther

Household size
1 person3 people5 people
2 people4 people6+ people

Income
0 - $4,999$20,000 - 29,999$40,000 - 49,999
$5,000 - 9,999$20,000 - 29,999$50,000 and above
$10,000 - 14,999$30,000 - 39,999

---

PROGRAM DETAILS
(check all that apply)

Mailing Lists

Outside Agency Mail (Permission to give out mailing info to non-profit agencies)

Other Programs Offered

Preschool ProgramKindergarten Enrichment Schoolage ProgramHead Start Summer CampSchool Readiness Program

Funding / Subsidy

FIA direct paymentsParent Co-op Sliding fee scaleHead Start Sibling discountSchool Readiness Program

Meals

BreakfastDinnerBring Own AM snackEvening snack4C Food Program LunchSpecial dietOther Food Program PM snack

Environment

Fenced YardNear public transportationHas pet(s) Pool / LakeNo petsSmoke Free

  Please list pets

Special Services

Provide Transportation

Provide Transportation Elementary Grades Onsite

I will transport to the following schools:

Special Needs

ADD/ADHDDown SyndromePhysically Handicap AsthmaDrug Exposed (prenatal)Seizure Disorder AutisticEmotionally ImpairedSpeech Impaired Breathing TreatmentEpilepsySpina Bifida Cerebral PalsyFeeding TubeVisually Impaired Cystic FibrosisHearing ImpairedOther, please specify DiabetesMentally Impaired

---

CREDENTIALS

License number
Date of original license (month/day/year)
Date license will expire (month/day/year)

First Aid / CPR up-to-date?
Valid and Current First Aid and CRP Certification
Certification not yet updated First Aid Expires (month/day/year)
CPR Expires (month/day/year)


Do you require parents to sign a written contract?
Yes
No

Experience / Training

Experience 2-5 yearsSoup and Salad Grant Experience > 5 yearsMaster's Degree in Early Childhood Experience > 10 yearsBachelor's Degree in Early Childhood Experience as a parentAssociates Degree in Early Childhood Special Needs ExperienceBachelor's Degree in Other Field Start Up GrantAssociates Degree in Other Field EQUIP GrantChild Development Associates Credential (CDA) NAFCC AccreditationAt least 45 hrs-Early Child Ed Workshops, conferences

Languages

SpanishDutchRussian Spanish OnlyFrenchSign Language ArabicGermanVietnamese ChineseJapaneseOther CroatianPortuguese Please list other

 

Training Series

MCC_Futures_BasicInterview, contract MCC Futures AdvancedRecordkeeping MCC Futures Admin

Membership

Kent Regional 4C FCCA (Family Child Care Association) NAEYC (National Association for the Education of Young Children) NSACA (National School Age Care Alliance) NAFCC (National Association for Family Child Care) NBCDI (National Black Child Development Institute)

---

SCHEDULE DETAILS Please record your hours of operation below.

	Time Open (1st shift)	Time Closed (1st shift)	Time Open (2nd shift)	Time Closed (2nd shift)	Time Open (3rd shift)	Time Closed (3rd shift)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Flexible Schedule?
Yes
No Schedule Type

Full-time Part-time

Year Schedule

Full Year School Year Only Summer Only

Shift Schedule

First ShiftEveningBefore school MorningSecond ShiftAfter school AfternoonOvernight

Week Schedule

Rotating schedule Weekends

Special Schedule

---

COSTS / VACANCY DETAILS Costs - Please fill in applicable amounts below
FT = Full Time
PT = Part Time

Age Group	FT Weekly	FT Daily	FT Hourly	PT Weekly	PT Daily	PT Hourly
Infant (0-17 months)
Toddler (18 m-2.5 yrs)
Pre-school (2.5 -5 yrs)
Kindergarten (5-6 yrs)
School-age (6-12 yrs)

Vacancy Information

Age Group	# 1st shift vacancies	# 2nd shift vacancies	# 3rd shift vacancies
Infant (0-17 months)
Toddler (18 m-2.5 yrs)
Pre-school (2.5 -5 yrs)
Kindergarten (5-6 yrs)
School-age (6-12 yrs)

Age of youngest child you would ever accept
Age of oldest child you would ever accept

Total capacity as listed on your license
Total Number of first shift vacancies you have now

For what ages do you have first shift vacancies?
  

Please list public elementary schools that are within walking distance from
your home, or that there is transportation to/from the school to/from your home.
  

---

Questions or comments?


  

Thank you for completing this form. If you need assistance, please call 1-800-448-6995 or 616-451-8281.