Please complete the form below to update your profile.

Contact Information

Program Type: Licensed Home Licensed Group Home Unregulated Home
Name on License:		License #
Contact Person Details
First Name		Last Name
Address 1		Address 2
City		State Select State Kansas Missouri
Zip + 4		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 + 4
A UAW-Ford employee's child attends this center.
An AT&T employee's child attends this center.

Location Information

Preferred Capacity (Not to exceed licensed capacity)

Total Vacancies

Ages Served (Ages you will care for, not the ages you currently have in care):

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

Rates

Age Group Full Time Cost (Please indicate hourly, daily, weekly, etc.) Part Time Cost PER HOUR 0 - 12 Months $ $ 13 - 24 Months $ $ 25 - 36 Months $ $ 3 - 5 Years $ $ Kindergarten and Older $ $

Capacity & Vacancies

Age Group Capacity (most children you will care for per age group) Current Full Time Vacancies (per age group) Current Part Time Vacancies (per age group) Current Children Number of children enrolled (per age group) 0 - 12 Months 13 - 24 Months 25 - 36 Months 3 - 5 Years Kindergarten and Older

Registration Fees Per Child Per Family

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) Hours are the same for each day Hours are different (specify)

Schedule Options

Full Time (more than 30 hrs/wk) Open Full Year Part Time (less than 30 hrs/wk) Open School Year only Part Time (birth-2 yrs.) Open Summer only Before School Rotating Sched. After School 24 Hour Care Before Kind. Open Holidays After Kind. Drop-in Full Week Hourly Part Week Temp/Emer. Care Weekend Flexible

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

Offerings Which of the following do you offer?

DFS Contracted Sliding Scale for DFS families Multi-child Discount Sliding Scale for non-DFS families Scholarship

Meals What meals do you serve?

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

Programs What type of programs do you offer?

Creative Curriculum Project Construct Montessori Not-for-Profit Preschool For-Profit School Age Care Reggio Early Head Start Mixed Age Head Start PreKindergarten Parent Co-op Religious Parent Day Out

Special Services

Mildly ill care Toilet training

Additional Features

List any additional languages spoken other than English:

List any additional languages taught in class other than English:

List the school district where your program is located:

Elementary Schools served:

Near public transportation I provide transportation to/from child’s home By bus to & from school I provide transportation to/from school School is within walking distance

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

ADD/ADHD Diabetes Medication Administration Allergies Down Syndrome Shunt Knowledge Asthmas Drug Exposed Speech/Language Autism Emotional Problems Spina Bifida Behavior Disorder Epilepsy/Seizures Trach Tube Breating Treat. Hearing Impairment Tube Feeding Catheter HIV/Hepatitis B Vision Impaired Cerebral Palsy Hydrocephalus Other Dev. Delay Injections

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

Adaptive Equip. Wheelchair Access Apnea Monitors Other

Special Needs Services Do you provide or are these services provided on-site for children with special needs?

Developmental/Cognitive Therapy Speech/Language Therapy Occupational Therapy Special needs transportation Physical Therapy

Referrals

Telephone Referrals (Check One) I would like to be referred to parents by The Family Conservancy SM 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 my first and last name, street address, city, state, zip code and telephone number will be available to parents using the on-line referral program. 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.