MCRDC - Provider Registration Form

A. Program Contact Information:

1. Your Name:
First Name	MI		Last
Job Title

2. Business Information:
Business Name
Mailing Address Line 1
Mailing Address Line 2
City		State		Zip Code

Location (if different from Mailing Address):
Location Address Line 1
Location Address Line 2
City		State		Zip Code

Main Phone (with Area Code)
Second Phone (with Area Code)
Fax (with Area Code)
Email			Website

3. Contact Person:
First Name	MI		Last

Referal and Contact Status	Refer for future careTemporarily not doing careNo referralsMailing list only
4. Licensing Information:
	Regulated/licenced provider with State of MaineExempt/unregulated
License ID	Expiration DateEIN/SSN

B. Program Overview:

1. Type of Program:
Check all that apply:	Child Care Center	Nursery School	Preschool
Check all that apply:	Family Child Care	Head Start	School-Age Program
	Before school	After School	Temporary/Emergency
	Drop-in	Overnight	Weekend
	Holidays	Camp	Employer based
	Evenings (past 6PM)	2nd Shift	3rd Shift
	Offers Lessons	Driving Field Trips	Walking Field Trips
	Follows a Curriculum	Religious Activities
	Other (explain below)


2. Ages of Care:
Ages accepted:	From yrs. months weeks to yrs months weeks
Check all that apply:	Infant		Kindergarten
Check all that apply:	Toddler		School Age
	Preschool		Other (please explain)

3. Schedule of Care:
Full or Part time Operation	Full Time	Part Time	Both	Other (please explain)

Hours and Days Open:	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday
Hours and Days Open:

Sessions:		Year Round		School Year Only		Summer Only		Other (please explain)

4. Capacity Information:

Age Group	Age Range
Infant	6wks-1yr
Toddler	1-3 yrs
Preschool	3-5 yrs
SchoolAge	Kindergarten
SchoolAge	1st grade +

Licensed Capacity	Desired Capacity	Subsidized Capacity	Full Time Vacancy	Part Time Vacancy	Vacancy Date	Enrolled	Adult/Child Ratio

C. Services:

1. Which meals are provided?

BreakfastAM SnackLunchPM SnackDinnerNone

USDA Food ProgramFormulaSpecial Meal Request

Parents Provide LunchParents Provide Meals

2. Transportation:

Is transportation provided?

Yes No

Is the program near
public transportation?

Yes (if Yes,what kind?)No

Is the program near school
bus routes?

Yes (if Yes,which ones?) No

School Districts that you serve.

Nearest Elementary School(s)

Approx. distance mi

In Walking Distance

Approx. distance mi

In Walking Distance

6. Fees:

(Check all that apply)

HourlyDailyWeeklyMonthlyYearlyOther

Rates:	Age Group	Age Range
	Infant	6wks-1yr
	Toddler	1-3 yrs
	Preschool	3-5 yrs
	SchoolAge	Kindergarten
	SchoolAge	1st grade +

Full time	Part time	Other	Comments

Do you offer a Sibling Discount?

Yes (if Yes,please explain) No

Please list all the forms of
financial assistance you offer
or accept.

Additional fees

Late payment fee	Drop-in		Preschool
Late pick-up fee	Bounced check fee		Field trip
Lessons	Holidays
One time registration fee		Annual registration fee

Allowances

Provider Sick		Provider Vacation
Child Absence		Family Vacation

D. Philosophy, Staffing and Environment:

1. Philosophy:
Philosophy (if applicable)	High Scope	Montessori	Waldorf
	RIE	Reggio Emilio	Child Centered
	Other (please explain)


Accepts Subsidies (if applicable)	Vouchers/transitional	Contract Slots (formerly Title XX)
	ASPIRE	HomeStart (Head Start)
	Other (please explain)


Policies (check all that apply)	Written Contract	Written Handbook
Policies (check all that apply)	Other (please explain)


2. Staff Training and Experience:

Special Skills (check all that apply)	American Sign Language	CNA Training	Multi-Lingual
Special Skills (check all that apply)	Other (please explain)


Safety (check all that apply)	CPR current within 2 yrs.	First Aid Training	Health related degree
Safety (check all that apply)	On-site nurse	Liability Insurance	Video Monitors
	Other (please explain)	Password/Passkey admittance Audio Monitors


Special Needs (check all that apply to your experience in the past or curently)	Training/education	Experience	Wheelchair accessibility
	ADHD/ADD	Asthma/Allergies	Developmental Delay
	Diabetes	Hearing	Emotional/Behavioral
	HIV/Hepatitis B	Medically fragile	Monitor
	Physical	Seizures	Tube feedings
	Visual		< 1 year experience
	1-3 years experience	3-7 years experience	> 7 years experience
	Other (please explain)


Training within the past year (check all that apply)	More than 12 hours of workshops and training specific to early care and education
Training within the past year (check all that apply)	13-40 hours of workshops and training specific to early care and education
	> 40 hours of training	MRTQ training
	Other (please explain)	College courses for credit


Experience	< 1 year	1-3 years	4-9 years
	10-20 years	21 + years	Nanny experience
	Family Child Care	Child Care Center	Elementary school experience
	Other (please explain)


Education	High School Education	Some college, child related	Some college, other
	CDA	Associate's, child related	Associate's, other
	Some child development courses	Bachelor's, child related	Bachelor's, other
	Some child development courses	Master's, child related	Master's, other

Accreditation	NAFCC	NAEYC	NSACCA
	Other (please explain)	In process


Advocacy	Phone tree leader	Phone tree participant	Write letters
	Visit legislators	On mailing list	Media contact
	Focus groups	Receive e-mail alerts
	Other (please explain)


Do you provide respite care?	YesNo

Center Information Only (check all that apply)	Residential	Non-residential	Faith-based
Center Information Only (check all that apply)	Workplace based	Volunteers	Parent Advisory
	> 3 sites	Intergenerational	Family style meals
	Scholarships (to parents)	Sliding Fee	Parent Cooperative
	Other (please explain)


Is there anything else about your company that you would like us to know?

3. Environment:	No pets	No indoor pets	No outdoor pets
	Special needs experience	Lead safe	Pool
(Check all that apply)	Smoke free	Fenced yard	Outdoor play
	Flexible morning hours	Flexible evening hours	Voucher provider
	Small group size (< 6)	Separate child care area	Accredited program
	May transport
Other comments

4. Quality Certificate (Apply to Department of Human Services for Certificate):
	Quality Certificate	Certificate #	Expiration date:

5. Activities Offered:	Walking field trips	Cooking	Circle time
	Driving field trips	Cultural activities	Arts and crafts
	Preschool curriculum	Music and movement	Religious
	Story time

6. Special Services:	Offers mildly ill childcare	Open snow days	Open school vacations
	CDS contract	Back-up care	Other

7. Paid Holidays Per Year:	4	7	10
	5	8	11
	6	9	12
	Will discuss

MCRDC Provider Registration Form