Provider Update Form

Child Care Aware of NWA

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- Child Care Aware of NWA
- Child Care Aware of the River Valley

Provider Update Form

Please complete this form and check all applicable boxes below.

* Indicates required field

Program/Business Name *

License Number *

Primary Contact/Director Full Name *

First

Last

Program/Business Address *

Line 1

Line 2

City

State

Zip Code

Country

Mailing Address(if different from Business Address) *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Fax Number *

Email *

Website URL or Facebook (if you have one) *

Type of Care *

Licensed FDC Home Registered FDC Home Licensed Center School Age Program Faith-Based Program Mother's Day Out Part-Time Preschool For Profit Non-Profit

Operation Schedule *

Full Year School Year Summer Only Drop-In

Days Open *

Sunday Monday Tuesday Wednesday Thursday Friday Saturday

Part-Time Option 1 *

Option 1 Option 2 Option 3

Part Time Option 2 *

Sunday Monday Tuesday Wednesday Thursday Friday Saturday

Hours of Operation

Monday *

Tuesday *

Wednesday *

Thursday *

Friday *

Saturday *

Sunday *

Ages Served:

Licensed Age From *

Licensed Age to *

Total Capacity *

Desired Capacity *

Full Time Vacancies *

Part Time Vacancies *

Full-Time Rates

Age *

0-18 Months

$ Rate *

Per *

Hour Day Week Month

Age *

18-36 Months

$ Rate *

Per *

Hour Day Week Month

Age *

2 1/2-5 Years

$ Rate *

Per *

Hour Week Day Month

Age *

School Age-Summer

$ Rate *

Per *

Hour Day Week Month

Part-Time Rates

Age *

0-18 Months

$ Rate *

Per *

Hour Day Week Month

Age *

18-36 Months

$ Rate *

Per *

Hour Day Week Month

Age *

2 1/2 - 5 Years

$ Rate *

Per *

Hour Day Week Month

Age *

School Age-Before School

$ Rate *

Per *

Hour Day Week Month

Age *

School Age - After School

$ Rate *

Per *

Hour Day Week Month

Age *

School Age - Summer

$ Rate *

Per *

Hour Day Week Month

Number of Staff *

Enviornment *

Enrichment Activities Computers/Technology Pets Field Trips

Health/Safety *

Heart Association/Red Cross First Aid/CPR Certified Medical Related Certification Developmental Delay & Disability Training Nutrition & Physical Activities Policy Other

Meals Served *

Breakfast Morning Snack Lunch Afternoon Snack Dinner Late Snack Special Meal Request USDA Food Program CCFP Participant

Accreditation *

Better Beginnings Getting Ready Level 1 Level 2 Level 3 NAEYC NAFCC CARF NAEYC ASAP Other

Transportation *

Do Not Transport Transport Provided On School Bus Route To and From Home Near Public Transportation Walking Distance to School

Financial Assistance *

ABC Program Head Start Multi-Child Discount TANF TEA Voucher Program Career Pathways Military Child Scholarships

Special Needs *

Dispensing Medicine Emotional/Behavioral Feeding Tubes Health/Mental Disability Monitors Occupational Therapy Physical Disability Special Diets Speech Wheelchair Accessible

Additional Professional Development *

Meets Min Licensing Training Standards Exceeds Min Licensing Training Standards

Director/Owner Education *

(CDA) Child Development Associate Associates Degree or 60 college hours 21-30 college hours for ECE/CD 9-21 college hours for Management Bachelor's Degree Master's or Other Advanced Degree

Director/Owner Experience *

0-5 Years 6-10 Years 11-15 Years 16-20 Years More than 20 Years

Do you charge parents if their child does not attend (i.e. family vacation time, child sick, etc.)? *

Comment *

Submit

Child Care Aware of Northwest Arkansas
1401 S. 8th Street
Rogers, AR 72756
E-mail: info@nwachildcare.org
Phone: (479)899-6374

Child Care Aware of River Valley
7200 Mahogany Avenue
Fort Smith, 72916
E-mail: info@nwachildcare.org
Phone: (479)222-6930

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