Provider Profile

Child Care Professional Profile

Please fill in the following information. If an item doesn't apply or you don't know the answer, just leave it blank.
Use the Tab key or mouse to transit between fields.When you are finished, click on the "Submit" button at the bottom of the form.

This profile allows us to collect and track data related to child care in our region. It is placed in a data base thats sole use is to help
parents find the best possible match for their child care needs. Thank you for helping us do our job of helping you do yours!

Name on License or Registration:

Business Name as printed on license or registration:

Contact Person: Title:

How is your facility regulated through KDHE? Select one: (If you have more than one, please complete a separate form
for each regulation ID)

Child Care Center
Family Child Care
Preschool
School Age Program
KDHE regulated Head Start Center
Exempt from KDHE Regulations

In what year did you first provide childcare?

Would you like to be referred to families needing child care? Yes No

Would you like to be referred to families through our on-line referral system? Yes No

Would you like for us to print your rates for families needing child care referrals? Yes No

Location of Facility: (street address)

City: Zip: County (Highlight One)

Mailing address (If different from Location address)

City(If different from Location address): Zip(If different from Location address):

Primary phone: Extension Secondary Phone: Extension Fax:

Email Address: Web site:

Is your facility regulated by KDHE? Yes No
What is your license number? License Expiration Date:

Check your license type:

Family Child Care Group
Family Child Care Licensed
Family Child Care Registered
Child Care Center
Preschool
School Age Program
Temporary KDHE Regulation
KDHE regulated Head Start Center
Exempt Head Start Or School Age Program
Non-KDHE Regulated Head Start or School Age Program
Other Non-KDHE Regulated Facility (please list)

What is your total license capacity (at any one time)? What is your total desired capacity (at any one time)?

What is the total maximum number of vacancies you have(at any one time)? As of what date?

What ages of children do you accept? From Through What School District are you in?

List the schools that are near your facility:

List those you offer transportation to:

Do you receive Head Start Funding? Yes No Do you receive Pre-K Funding? Yes No

Check all appropriate items regarding transportation:
On or near school bus line Walking distance to School Near Public Transportation
Transportation provided for all events, school, etc. Field Trips Only to/from full day school
Only to/from part day school Only to/from preschool To/from Client's home

Check any languages you use in your home:
English Spanish Cambodian French German Italian Japanese Laotian Portuguese Polish
Native North American Languages Russian Serbo-Croatian Sign Language Thai Vietnamese/Hmong Sarsi

Shift Information
Do you have a waiting list? Yes No
If yes, when are your openings available?
Does your facility charge a fee for child care? Yes No

We can list three shift options in our database. Please indicate the Start Time and End Time for each shift that your facility is open. Day shift covers hours from 6:00 a.m. until 6:30 pm. Enter school year and summer/holiday shifts only if you do not offer care the entire calendar year. Full time care is to be completed only if you offer care for more than 35 hours per week. Preschool and school age care would be listed as part time care.

What days is your facility open? (check appropriate boxes)

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Shift	Start Time	End Time	Check Items that Apply:
Day			I accept children:
Evening			Full Time Part Time Both
School year ONLY
Summer ONLY
Preschool 2-days			Before School
Preschool 3-days			After School
Preschool 5-days			Temporary Emergency
Weekend			Rotating 24 hours
Overnight			Open Holidays

Age	Full Time Cost Please Indicate Unit Hourly Daily Weekly Monthly	Part Time Cost Please Indicate Unit Hourly Daily Weekly Monthly	Licensed Capacity	Current Enrollment (be sure to include Part-Time children)	Desired Capacity	Number of Full Time Vacancies	Number of Part Time Vacancies
Under Age 1
Age1 thru 17 mo.
18 months to 2
Age 2
Age 3
Age 4
Age 5
Age 6 & Over

Additional comments about your shift(s):

Do you have any scheduling comments you would like included in our database?

Environment please check all that apply to your facility:

ADA Accessible Indoor	ADA Accessible Outdoor	Above or In-Ground Pool
Air Conditioning	Air Purifier	Basement used for shelter only
Basement used for child care	Dehumidifier	Designated Play Area (FCC)
Fenced Yard	No Pets	Non-Carpeted Environment
Outdoor Pets Only	Small Group of 6 or fewer children	Smoke Free
Smoking non-business hours only	Wading Pool

Meals check all that are offered by your program:

CACFP/USDA Food Program	Breakfast	Morning Snack
Lunch	Afternoon Snack	Evening Meal
Evening Snack	Supports Breast Milk	Infant Formula/Infant Food Supplied
Special Diet

Philosophy

Creative Curriculum	Developmentally Appropriate Practices	High Scope
Montessori	No Curriculum Used	No Television
Own Curriculum Used	Reggio Emelia	Religious Curriculum
Waldorf

Policies

Written Agreement/Contract	Written Handbook	Billing Weekly
Billing Monthly Billing Bi-Monthly	Billing on First of Month for Entire Month	No Notice Required When Family Resigns
Less Than 1 Week Notice Required When Family Resigns	One Week Notice Required When Family Resigns	Two Weeks Notice Required When Family Resigns

Special Skills Teach Spanish Teach Sign Language

Safety

CPR Current Within 2 Years	First Aid Training Within Past 12 Months	On-Site Nurse
Child Care Health Consultant Agreement Liability Insurance Covering Child Care Business

Special Needs check only those areas in which you have specialized training or experience

ADHD/ADD	Abuse & Neglect (witness or victim)	Allergies	Apnea monitor
Asthma	Autism/Asperger Syndrome/PDD	Cerebral Palsy	Cystic Fibrosis
Developmental Delays	Diabetes	Downs Syndrome	Emotional Delays
Epilepsy/Febrile	Gastronomy/Tube Feeding	HIV/AIDS	Hearing Impairment
Maternal Substance Abuse	Medically Fragile	Mental Illness
Nutritional Deficiency	Visual Impairment

Training Check those you have completed within the past 12 months

No Professional Development	1-5 In-Service Hours	6-10 In-Service Hours	11-20 In-Service Hours
> 20 In-Service Hours	.4-2 CEUs	3-6 CEUs	7-10 CEU's
> 10 CEUs	Early Childhood College Credits

Experience mark the experience you have within the early childhood/school age field:

Under 1 Year 1-3 Years 4-9 Years 10-20 Years > 20 Years

Check the type(s) of your early childhood/school experience:

Family Child Care

Child Care Center

Preschool

Elementary School

Para

Education check the highest level completed (also check any Early Childhood Degrees as well)

Some High School	High School Diploma or GED
Associate Degree in Early Childhood	Associate Degree in Non-Early Childhood
Bachelor's Degree in Early Childhood	Bachelor's Degree in Non-Early Childhood
Master's Degree in Early Childhood	Master's Degree in Non-Early Childhood
Doctorate in Early Childhood	Doctorate in Non-Early Childhood

Accreditation: NAFCC NAEYC

Affiliation:

NAFCC	State FCC Association	Local FCC Association
NAEYC	State AEYC	Local AEYC

Advocacy:

Member of KACCRRA	Member of NAEYC/KAECY or local AEYC affiliate	Member of Provider's Group
Member of CCPC	Participate in Local Advocacy Events	Participate in Advocacy Conferences
On Mailing list for Legislative Issues	Visit with Legislators	Write Legislators

Financial Options What financial options do you offer to your clients?

SRS	Sliding Scale/Non-SRS	Foster/Adoption
Local Financial Assistance	KCSL	Military Subsidy
Multi-Child Discount	Scholarships	Youthville

Type of CDA (Child Development Associate) must be current :

Family Child Care Center Based Infant Toddler & Preschool Home Visitor

Intentionality regarding your work in the early childhood/school age field:

Career or Profession	Stepping Stone to a related career or profession
Personal Calling	Job with a paycheck
Work to do while my children are at home	Way of helping a family member, neighbor or friend

Early Childhood College Credits:

0
1-6
7-12

13-24
25-48
49-72

73-96
97-120
>120

Professional Development check any that you have completed within the past 12 months

EBT (Electronic Benefit Transfer)	Q-Tip Oh! Filling the Gap
KCCTO	DYFCCB (Developing your Family Child Care Business)
Infant/Toddler Professional Development Events	NACCRRA Conference
KACCRRA State-Wide Professional Development Events	CCR&R Sponsored Professional Development Events

Core Competency Area check all you have completed training in within the past 12 months

I: Child Growth & Development	II: Learning Environment & Curriculum
III: Child Observation & Assessment	IV: Families & Communities
V: Health, Safety & Nutrition	VI: Interactions with Children
VII: Program Planning & Development	VIII: Professional Development & Leadership

Program Participation

ELOA EXCEL Early Head Start Smart Start T.E.A.C.H. WAGE$

Family Child Care Owners complete this section. If your facility is regulated as a Child Car Center, Head Start Center, Preschool or School Age Program, please skip this section and go to the Next Section.

Family Care Setting:

House Apartment Townhouse Mobile Home Duplex Non-Residential

Income what is your annual net income from your child care business?

Benefits check the benefits you have even if they are not paid by your child care business

Health Insurance	Dental Insurance	Life Insurance
Sick Leave	Vacation	Professional Development Leave
Retirement	Short-Term/Long-Term Disability	Company Vehicle/Vehicle Insurance

Census Questions

Is the owner of the facility Spanish/Hispanic/Latino? Yes No

Race? Ancestry or Ethnic origin?

Is there a language other than English that is spoke in your home? Yes No What Language?

Please include any comments you would like included into the database regarding your setting or languages spoken:

Family Child Care Owners: Thank you for completing our profile form. Please proceed to the bottom of the page and click on the "Submit" button. The following section is to be completed by only by Child Care Centers, Head Start Centers, Preschools and/or School Age Programs.

Child Care Centers, Head Start Centers, Preschools and School Age Programs please complete this section.

Setting:

Non-Residential	Faith-Based	Workplace-Based
Residential	School-Based	Outdoor Summer Camp
Military-Based	Tribal-Based	Campus-Based

Staff Information Complete the following table regarding your staff salaries and benefits. List the number of staff in each position,the range of salary and check any benefits your child care business offers within each staff title.

Staff Title

# of Staff in
This
Position

Low
Pay
Range

High
Pay
Range

Health
Ins.

Dental
Ins.

Life
Ins.

Sick
Leave

Vacation

Professional
Development
Leave

Retire-ment

Short/
Long
Term
Dis.

Vehicle &
Or Ins.
Furn.

Administrator

Director

Assistant
Director

Program
Director

Lead
Teacher

Co-Teacher

Assistant
Teacher

Non-Teaching Staff

Census Questions for Child Care Centers, Head Start Centers, Preschools and School Age Programs:

How many staff memebers are Spanish/Hispanic/Latino:

Mexican/Mexican American/Chicano	Puerto Rican	Cuban
Other Spanish/Hispanic/Latino (Print Group)
How many staff members do you have whose race is:

White	Black	American Indian or Alaska Native (which tribe?)
Asian Indian	Native Hawaiian	Chinese	Filipino
Japanese	Vietnamese	Other Asian (print race)
Guamanian or Chamorro	Samoan	Other Pacific Islander (print race)

How many staff do you have that speak a language other than English at home?

What languages?

How well do these staff speak English? Very Well Well Not Well Not at all

Please include any comments you would like to have included into the database regarding your setting or languages spoken:

Thank you for completing our profile form.

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