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Contact Information

Program Type: Licensed FCC Group FCC Registered FCC
Name on License:		License #
Contact Person Details
First Name		Last Name
Address 1		Address 2
City		State Select State Kansas Missouri
Zip		County Select County Kansas Counties Atchison Brown Doniphan Franklin Jefferson Johnson Leavenworth Miami Wyandotte ---------------- Missouri Counties Bates Cass Clay Jackson Lafayette Platte Ray Saline
Phone		Fax
Email
Mailing Address (if different)
Address 1		Address 2
City		State Select State Kansas Missouri
Zip

Location Information

Preferred Capacity (Not to exceed licensed capacity)

Total Vacancies

Ages Served

What is the age of the youngest child you are willing to provide care for? Years Months

What is the age of the oldest child you are willing to provide care for? Years Months

Day Rates

Age Group Full Time Cost (Please indicate hourly, daily, weekly, etc.) Part Time Cost PER HOUR 0 - 17 Months $ $ 18 months up to Kindergarten $ $ Kindergarten and Older $ $

Day Capacity & Vacancies

Age Group Capacity (most children you will care for per age group) Current Vacancies (per age group) Current Children Number of children on waiting list (per age group) 0 - 17 Months 18 months up to Kindergarten Kindergarten and Older

Night Rates

Age Group Full Time Cost (Please indicate hourly, daily, weekly, etc.) Part Time Cost PER HOUR 0 - 17 Months $ $ 18 months up to Kindergarten $ $ Kindergarten and Older $ $

Night Capacity & Vacancies

Age Group Capacity (most children you will care for per age group) Current Vacancies (per age group) Current Children Number of children on waiting list (per age group) 0 - 17 Months 18 months up to Kindergarten Kindergarten and Older

Features & Services
What days does your program operate? Monday Friday Tuesday Saturday Wednesday Sunday Thursday		What hours do you care for children? Open (am/pm) Close (am/pm)

Facility Type

Full Time (more than 35 hrs/wk) After Kind. Part Time (less than 35 hrs/wk) Flexible Before School Drop-in After School Rotating Sched. Before Kind.

Environment

Air Conditioner Fenced Yard Air Purifier No Pets Dehumidifier Smoke Free (no one smokes in the home at any time) Dedicated Indoor Play Area Swimming Pool

Pets

Dog(s) Pets Kept Away From Children Cat(s) Other Outdoor Pets Only

If "other" please specify

Training What training have you completed?

AA Early Childhood Education MA/MS (Master's Degree-other field) AA (Associate's Degree-other field) CDA BA/BS Early Childhood Education Pediatric CPR BA/BS (Bachelor's Degree-other field) First Aid MA/MS Early Childhood Education KCCTO Hours

Offerings Which of the following do you offer?

SRS Contracted Scholarship Multi-child Discount Sliding Scale

Meals What meals do you serve?

Breakfast Dinner Morning Snack Evening Snack Lunch Child Care Food Program Afternoon Snack

Additional Features

List any additional languages spoken other than English:

List the school district where your program is located:

Elementary Schools that transport to your program or schools that you transport to:

On or Near Metro Bus Route to/from Full Day School to/from Kindergarten

Special Needs Training Do you have experience or special training with children with special needs?

ADD/ADHD Diabetes Organ Transplant Allergies Dialysis Retts Syndrome Anger Disorder Down Syndrome Speech/Language Asthma Emotional Problems Trach Tube Autism Epilepsy Tube Feeding Behavior Disorder Hearing Impairment Vision Impaired Cerebral Palsy Mental Retardation Other

Special Needs Equipment Do you have any special equipment to accomodate children with special needs?

Adaptive Equip. Infant Monitors Apnea Monitors Professional Equipment Handicap Accessible Transportation Wheelchair Access

Referrals

Telephone Referrals (Check One) I would like to be referred to parents by The Family ConservancySM through their Early Education Specialists. I understand I may be removed from the listing at any time if I so choose. I would Not like to be referred to parents by The Family ConservancySM through their Early Education Specialists. I understand I may be added to the listing at any time if I so choose.

On-line Referrals (Check One) I would like to have my child care business listed on the Child Care Source website for parents to access for referral purposes. I understand that I may be removed at any time if I so choose. I would Not like to have my child care business listed on the Child Care Source website for parents to access for referral purposes. I understand that I may be added to the listing at any time if I so choose.

Your program will be included in referrals if the telephone and on-line referral options are left blank.