CCR&R-MC Family Child Care Provider Enrollment/Annual Update Form
4510 NE 102nd Ave, Portland, OR 97220
Phone (503) 491-6200 Toll Free (866) 227-5529 Fax (503) 491-6930
Contact Information & Regulation
First Name:
Last Name:
Business Name:
Do you want CCR&R to refer parents to your child care
business?
Yes
No
Do you want your business listed in the website for online child care searches?
Yes
No
Street Address
How would you like to be contacted?
Address & Apt #
City
Phone:
(
)
Secondary Phone:
(
)
Fax Number:
(
)
Email for parents to use:
Email for CCR&R use (if different):
State: OR
Zip:
Mailing Address (if different)
Address & Unit No.
City
State: OR
Zip:
Website:
Regulation (Office of Child Care – OCC)
DHS Listing Information
If Licensed, what is your OCC license number?
If Listed, what is your DHS provider number?
Children in Care
How many children, including your own, are you willing
to care for at any one time?
Total:
How many total vacancies do you
currently have?
Youngest age accepted:
Oldest age accepted:
Schools, Transportation and Languages
Schools Information
Transportation
What school district is your Family Child Care
Home located in?
Centennial
Parkrose
Corbett
Portland
David Douglas
Reynolds
Gresham-Barlow
Riverdale
Elementary schools nearby:
Mark the transportation options that are available or that you offer.
Many parents need help with transportation.
Transportation provided
Transports to/from preschool
Near School Bus
Transports to/from multiple schools
Transport to/from designated school
Near Public Transportation
Transport to/from activities
Transports to/from Kindergarten
Walking distance to school
Transports to/from Child’s Home
Languages
What languages are spoken fluently at your child care home?
What is your PREFERRED language?
Schedule Information
What are the hours of operation?
Day of the Week
Monday
Start Time
Tuesday
Wednesday
Scheduling Details
End Time
Full Time
Do you accept children:
Part Time
Both Full and Part Time
School year
Summer
Full year
Are you willing to provide care in any of these situations:
Thursday
Drop In
Temp/Emergency
Rotating Shifts
Friday
Before School
After School
Open Holidays
Saturday
Flexible am
Occasional evening
Occasional early morning
Sunday
Flexible pm
Occasional overnight
Occasional weekend
FCC Enrollment/update form – FCC-EN
24 hrs
Revised September 16, 2014
Rates and Fees
We do not share rate information with parents, but this information is important for statewide and county data analysis purposes.
What are your rates per hour, week, or month?
Age Group
Infants
Full Time
$
Part Time
Per
$
Do you charge fees in addition to your rates?
Per
Registration
$
Deposit
$
$
$
Toddler
$
Per
$
Per
Transportation
$
Meals
Preschool
$
Per
$
Per
Materials/book
$
Other fees
Per
Activity
$
School Age
$
Per
$
Environment, Meals, Educational Philosophy & Programming
Environment
No pets at all
No cats
No dogs
Pets separate from children
Meals
No TV
Monitored TV
No smoking at all
USDA Food Program
Parents bring meals
Special meal requests accommodated
Breastfeeding supported
Philosophy
Program Structure
Waldorf
Reggio Emilia
Do you offer a preschool program?
Montessori
Religious Curriculum
Is this a parent co-op?
Yes
Yes
No
No
Financial Assistance
Willing to accept DHS
Rates negotiable
Multi-child discount
Free to eligible clientele
NOT willing to accept DHS
Offers scholarship
Sliding fee scale
Parent co-op
DHS Listed
DHS enhanced rate
Special Needs
Have you had training in these
topics?
Inclusion
Diversity
Domestic violence/abuse
Behavioral issues
Medical support
Do you offer supports for children who have specialized needs?
(see attached sheet for definitions of special needs categories)
Challenging behavior
supervision and/or supports
Communication supports
Socialization supports
Diapering/Toilet assistance
I would like to be contacted for updates by:
I would like to receive my newsletter by:
Phone
Mail
Medication monitoring
Nursing Care
Mobility assistance
Physical therapy
Specialized equipment
Mail
Email
Wheelchair access
Accessible bathroom
No experience/willing to
learn
Hearing impaired
ADD/ADHD
Asthma
Autism
Diabetes
Vision Impaired
Fax
Email
I understand that CCR&R of Multnomah County only makes referrals, 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.

Signature
FCC Enrollment/update form – FCC-EN
Date
Revised September 16, 2014