Family Care Connection
Child Care Provider Intake Form
For Lincoln County mail or fax to:
OSU Extension Service
Child Care Resource & Referral
1211 SE Bay Blvd, Newport OR 97365
Fax: 541-265-3887
For Clatsop and Tillamook Counties mail or fax to:
OSU Extension Service
Child Care Resource & Referral
2001 Marine Drive Room 210, Astoria OR 97103
Fax: 503-325-7910
This form can be filled out online, and then printed, signed and dated, then mailed or faxed (see our information above). If you
prefer you can also print the form, then fill it in, sign and date, and mail or fax.
First Name:
Last Name:
Business Name:
Date first began care (approximate is ok):
Information about your childcare facility will automatically be placed on the Oregon Child Care Resource and Referral Network
Internet Online Search, available to parents looking for child care. To check out the internet search, visit the Oregon Childcare
Resource and Referral Network at www.oregonchildcare.org
If you prefer, you may choose to opt out of the Internet Online Search by checking this box:
Address:
City
State
Zip
Mailing Address (if different)
City
State
Zip
Primary Phone:
Secondary Phone:
Fax Phone:
Cell Phone:
Common Identifier:
—
The common identifier is the last 5 digits of your Social Security number, then a dash,
followed by your date of birth using a 4-digit year. For example: 12345 — 01011975.
Oregon Child Care partners, including CCR&R agencies, are assigning a unique identifier (using the last five digits of SSN plus date of birth) for each early childhood care
and education professional across the state of Oregon. This identifier will allow researchers to track anonymous data to better understand the characteristics of Oregon’s child
care workforce. The information will be used to assess current training efforts, to design training programs that meet the needs of child care providers and to advocate on
behalf of Oregon’s child care professionals.
Website address:
Email:
Update by email Yes
**Emails and Website addresses provided WILL be posted on the State website if web referrals are indicated.
License
Registered or Certified
Registration #
Expiration Date:
Type
Exempt (not registered with the Child Care Division, or DHS listed only)
Do you have a preschool program with separate enrollment Yes
No
Preschool Curriculum Yes
Accepts Children
FROM AGE
yrs
mo
wks
TO AGE
yrs
No
No
mo
wks
Desired Capacity:
How many you would like to enroll. Family Child Care Providers: Do not include YOUR OWN children.
Current Openings:
Specify what ages you can take
up to 1 yr
1-2 yr
Family Child Care Providers: DO YOU have children of your own at home? Yes
Transportation Provided
Yes
No
2 yr to 1st grade
No
1st grade up
If yes, what are there ages?
What public school does or would your children attend?
If transportation is provided what schools will you transport to/from?
Near School Bus
Walking Distance to School
Near Public Transportation
Transports to/from Designated Area School
Transports to/from Preschool
Transports to/from Kindergarten
Transports to/from Sports/Activities
Transports to/from Multiple Schools
Transports to/from Child's Home
Primary Language:
Other Languages spoken
Extended Hours Offered (mark all that you are willing to consider or accept)
Early morning (starting between 3 am and 5:59 m)
Evening (after 6:30 pm)
Overnight (at least between 10 pm and 3 am)
Weekend (regular care on Saturday and/or Sunday)
Occasional early morning
Occasional evening
Occasional overnight
Occasional weekend
Flexible am
Flexible pm Please list any scheduling conditions not listed above.
DAYS
Mon Tue
Wed
Drop In
Thur
Fri
Sat
Sun
Temp/Emergency
RATES
HOURS
FROM
AM
Before School
HOURS
TO
PM
After School
Rotating
FULL TIME (30 or more hours)
AM
24-Hour
PM
Open Holidays
PART TIME (less than 30 hours)
Under 1 yr
Hour
Week
Day
Month
Hour
Week
Day
Month
1 to 2 yr
Hour
Week
Day
Month
Hour
Week
Day
Month
2 yrs to Kindergarten
Hour
Week
Day
Month
Hour
Week
Day
Month
KINDERGARTEN
FIRST GRADE and OLDER
Before School
Hour
Week
Day
Month
Hour
Week
Day
Month
After School
Before AND After School
or Fulltime (Summers)
Hour
Week
Day
Month
Hour
Week
Day
Month
Hour
Week
Day
Month
Hour
Week
Day
Month
Registration fee
Deposit
Materials/book fee
Charge for transportation
Extra Charge for meals
Activity fee
Other fees (specify what type and amount)
(Mark all that apply)
ACCEPTS CHILDREN
Full time
ENVIRONMENT
No smoking on premises
No dogs
No TV
Covered outdoor play
Part Time
Both
School Year
Summer
No pets at all
Pets separate from children
Monitored TV
Outdoor play structure
MEALS
USDA Food Program
Provides breakfast
Provides dinner
Snacks provided
Special meal requests accommodated
Breastfeeding supported
PHILOSOPHY
Montessori
Waldorf
Reggio Emelia
FINANCIAL ASSISTANCE
* Please indicate one of these (not willing will
* Willing to accept DHS
* NOT Willing to accept DHS
Qualified for DHS enhanced rate
Multi-child discount
Rates negotiable
Offers scholarship
Parent co-op
No rates - not market care
Full Year
Any
No cats
Completely Fenced Yard
Outdoor play area
Provides lunch
Parent must bring meals
Religious curriculum
be marked if Willing is not)
DHS listed
Offers sliding fee scale
Free to income eligible
POLICIES
Written contract
Have backup provider (substitute)
Charges late fees
Written policies
Have references
Must be potty trained
Liability insurance
Pay for slot whether in care or not
Needs payment in advance
SPECIAL SKILLS
Inclusion training
Medical Support training
Domestic Violence/Abuse training
Diversity training
Behavioral issues training
SAFETY and BASIC TRAININGS
First aid
Recognizing/Reporting Abuse/Neglect
Working with DHS Families Provider
Training
CPR
Family Child Care Provider Overview
Child Care Health and Safety (any
module)
Food Handlers Permit
DHS Provider Orientation
SPECIAL NEEDS (Knowledge and or experience working with these types of needs)
Challenging behavior
Communications supports
supervision/supports
Diapering/toileting assistance
Mobility assistance
Nursing care
Physical therapy
Wheelchair access
Accessible bathroom
TRAINING
Dollars and Sense
First Connections (any module)
EXPERIENCE
Trained as child care provider mentor
K-elementary classroom teacher
EDUCATION
High school diploma/GED
Associate degree, child related
Bachelor's, other emphasis
No HS diploma/No GED
ACCREDITATION
First by Five (any module)
Center care experience
Experience with medical assistance
Previous family child care experience
Some college, child related
Associate degree, other emphasis
MA/MS or PhD
Some college, other emphasis
Bachelor's, child related
CNA/CMA/LPN/RN
NAFCC
Step 2
Step 5
Step 8 or 8.5
PROGRAM STRUCTURE
Homework assistance
Additional lessons
TRAC (any module)
NAEYC/NAECP
Step 3
Step 6
Step 9 or 9.5
NAA
Update by email
CDA
Provider network
OSAC
Stand for Children
Step 10 or above
Scheduled activities
Computer
Have you previously provided care in another Oregon county? Yes
PROVIDER PREFERENCES
Medication monitoring
Specialized equipment
No experience/willing to learn
Building Blocks Social and Emotional
(any module)
Starting Points (any module)
AFFILIATION (Contact Family Care Connection for additional information)
PRO
Other provider support organization
OACCD
OAEYC
NAFCC
OFCCN
Oregon Registry
Step 1
Step 4
Step 7 or 7.5
Socialization supports
Field trips
Organized outdoor activities
No
If yes, what county?
Update by fax
To receive mailings in Spanish
I understand that Family Care Connection's Child Care Resource & Referral (CCR&R) makes referrals only, not
recommendations, to families. I agree to assist the CCR&R in maintaining up-to-date information on child care
availability by reporting changes in my Family Child Care home when they occur. I give the CCR&R permission to
release the information on this form to parents seeking child care services. In addition, the CCR&R occasionally
releases the names and addresses of providers to carefully screened child care related agencies and organizations.
Unless otherwise indicated, I give Family Care Connection permission to release my name and address to such
agencies and organizations.
Signature: _______________________________________________ Date: __________________________
Please let us know any details you want us or parents to know about your program. This statement may also be used
on the searchable website.
Rev FCC 7-21-15