CCR&R-MC Child Care Center 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 - Director:
Last Name - Director:
Business Name:
Contact:
Contact Phone:
Do you want CCR&R to refer parents to your child care business?
Yes
No
Do you want your business listed on the website for online
child care searches?
Yes
No
Street Address
How would you like to be contacted?
Address & Unit No.
Phone:
City
State: OR
Zip:
(
)
Secondary Phone: (
)
Fax Number:
)
(
Mailing Address (if different)
Email for parents to use:
Address & Unit No.
Email for CCR&R use (if different):
City
State: OR
Zip:
Website:
Regulation (Office of Child Care-OCC)
Are you currently: Licensed
DHS Listing Information
Recorded
If listed, what is your DHS provider number?
What is your OCC regulatory number?
Children in Care
Capacity and Vacancies
What are the ages that you are willing to care for?
How many children in total are you willing to care for at any one time ?
Total:
Youngest Age:
Oldest Age:
Desired Capacity by Age Group (in care at any one time)
How many total vacancies do you currently have?
How many infants?
How many toddlers?
How many preschoolers?
How many school-age?
Languages
What languages are spoken fluently at your child care center?
What is your preferred language?
Center Enrollment/Update Form
September 17, 2014
Schools and Transportation
Schools Information
Transportation
What school district is your center located in?
Mark the transportation options that are available. Many parents need help with
transportation.
Centennial
Parkrose
Transportation provided
Transports to/from preschool
Corbett
Portland
Near School Bus
Transports to/from multiple schools
David Douglas
Reynolds
Transport to/from designated school
Near Public Transportation
Gresham-Barlow
Riverdale
Transport to/from activities
Transports to/from Kindergarten
Walking distance to school
Transports to/from Child’s Home
Elementary schools nearby:
Schedule Information
Your schedule information is an important factor when we search for referrals for parents. The more flexible and available you are in your
availability, the more likely you are to be referred to parents. Mark all options that may apply to the availability of your child care center.
What are the hours of operation?
Day of the Week
Start Time
Scheduling Details
End Time
Do you accept children:
Monday
Full Time
Tuesday
School year
Wednesday
Part Time
Both Full and Part Time
Summer
Full year
Are you willing to provide care in any of these situations:
Thursday
Drop In
Friday
Before School
After School
Open Holidays
Saturday
Flexible am
Occasional evening
Occasional early morning
Sunday
Flexible pm
Occasional overnight
Occasional weekend
Temp/Emergency
Rotating Shifts
24 hrs
**If you have more than one schedule, please attach a separate sheet showing the ages attending.**
Rates and Fees
We do not share rate information with parents, but the information is important for statewide and county data analysis purposes.
What are your rates per hour, week, or month?
Age Group
Part Time
Full Time
Do you charge fees in addition to your rates?
Infants
$
Per
$
Per
Registration Fee
$
Activity Fee $
Toddler
$
Per
$
Per
Deposit
$
Meals
$
Preschool
$
Per
$
Per
Materials/book fee
$
Other fees
$
School Age
$
Per
$
Per
Transportation Charge $
Center Enrollment/Update Form
September 17, 2014
Environment, Meals, and Educational Program
Environment
Meals
No TV
Monitored TV
Outdoor play area
Covered outdoor play
Outdoor play structure
Philosophy and Program Structure
Waldorf
Montessori
Reggio Emilia
Religious Curriculum
Provide breakfast
Provide lunch
Provide dinner
Parents bring meals
Special meal requests accommodated
Breastfeeding supported
Provide snacks
USDA Food Program
Preschool Curriculum
Do you offer a preschool curriculum?
Yes
No
Financial Assistance
Willing to accept DHS
Rates negotiable
Multi-child discount
NOT willing to accept DHS
Offers scholarship
Sliding fee scale
DHS Listed
DHS enhanced rate
Free to eligible clientele
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:
Phone
Mail
I would like to receive my newsletter by:
Mail
Email
Medication monitoring
Nursing Care
Mobility assistance
Physical therapy
Specialized equipment
Email
Wheelchair access
Accessible bathroom
No experience/willing to
learn
Hearing impaired
ADD/ADHD
Asthma
Autism
Diabetes
Vision Impaired
Fax
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 center when they occur.

Signature
Center Enrollment/Update Form
Date
September 17, 2014