Type of Care: ^*

 Child Care Center    Family Child Care Provider    Preschool Program only    Parent's day out program    Schoolage Program only          Summer Camp Program          After school mentoring/tutoring                Head Start Program (Head Start Funding)    Virginia Preschool Initiative (State Pre-K Funding)

Type of Regulation: ^*

     License ID (if licensed)

 State Licensed home or center   Family Child Care System Licensed   Voluntary Registration (homes only)   DSS locally approved home or individual   Religious Exempt Child Care Center   Certified Public School Preschool   Unregulated home or individual   State Exempt Instructional/Recreational   Military approved family child care home   Other

Rates / Fees

Other fees:

Meals:

Financial Assistance:

(Check all that apply:)

Policies:

 Written Contract    Handbook    Multi-child Discount    Liability Insurance
 Provider Sick Allowance    Provider Vacation Allowance    Child Absence Allowance

Safety:

 CPR Certified    First Aid Certified    Medication Administration Certified
 Health-Related Degree    On-Site Nurse

Special Needs:

(Check all that apply)
 Adaptive Special Equipment       Asthma/Respiratory       Allergies       ADD/ADHD
 Autism/Aspergers    CP/Neuralgic/Seizure Disorders    Developmental Delay    Cognitive
 Diabetes        Down Syndrome        Post Traumatic Stress Disorder        Medical
 ODD         Physical         Social/Emotional         Learning disabled resources
 Space for therapy     PT/OT     Experience/Training or desire to provide care

Experience:

Refers to the Center Director or Family Child Care Provider

Training/Education:

Refers to the Center Director or Family Child Care Provider (Specify area of study)

Acceditation:

 NAEYC        NAFCC        NECPA        NAC        NAA        COA        ACA

Affiliation:

 NAFCC      NAEYC      VAFCCA      VAECE      Local Family Child Care Assoc      Local AEYC

Child Advocacy Issues:

 Will visit legislators    Will contact legislators    Will write letters    Will make phone tree calls

Enrollment Requirements:

 Orientation   Medical Authorization   Physical-Health Record   Parent Information   Proof of Birth

Curriculum:

 ABEKA    Creative Curriculum    High Reach    High Scope    Houghton Mifflin Pre-K    Montessori    Mother Goose    Pinnacle    Reggio    Other

DO NOT include my information for:

 Web Referrals     Referrals to Parents     Rates     Training Information mailings

Sworn Disclosure:

I certify that the information on this form is true and correct, and that I am legally operating within the laws and child care regulations of the Commonwealth of Virginia. (Section §63.2-1727 of the Code of Virginia prohibits any person from operating a family day home if he, or if he knows that any person who resides, is employed by, or volunteers in the home, is a convicted sex offender or has a founded complaint of child abuse or neglect within or outside the Commonwealth.) I agree to enroll children without regard to race, color, religion, sex, age, veteran status, national origin, disability or political affiliation. I agree to notify (CCRR) within 30 days of any changes in the child care facility's phone number, address, regulation or certification status.

By submitting this form, I agree to the terms listed above.

Please enter today's date as your signature: ^* (MM-DD-YYYY)