YWCA Child Care Resource & Referral - Center Based Program Update

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Home Based Program Update - Toledo

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Program Information Form

Date:

xx/xx/xxxx

Contact Name:

Address:

City:

State:

Zip Code:

County:

Phone Number:

Fax Number:

Email:

Certification:

Services: (Check all that apply. You may check more than one item.)

Yes No

Are you certified?

If yes, what county?

License ID #

Expiration Date: xx/xx/xxxx

ODE: ODJFS:

From To

What are the ages of the children in your care?

School Age Care:

Yes No

Will you provide before and after school care?

If yes, what elementary school(s) are closest to you?

Yes No

Do you provide transportation?

If you don't provide transportation, how do you get children to and from school?

Days/Hours of Operation:

Check all that apply and fill in hours.

Monday

Hours From to

Tuesday

Hours From to

Wednesday

Hours From to

Thursday

Hours From to

Friday

Hours From to

Saturday

Hours From to

Sunday

Hours From to

Vacancies:

How many vacancies?

Day: Evening: Overnight:

Meals:

Breakfast

Morning Snack

Lunch

Afternoon Snack

Dinner

Evening Snack

Special Diet

Parent Provided

Environment:

Non-Smoking

Fenced Yard

Outdoor Play Area

Has A Pool

No Pets

Wheel-Chair Accessible

Has Pet Indoors

Near Public Transportation

List Pets:

Experience:

(If Yes, check all that apply.) Yes No

Do you have experience caring for children with special needs?

Speech/Hearing

Emotional/Behavioral

Physical/Mobility

Medical Conditions

MRDD

Visual

Program Fees:

Please indicate the dollar amount:

Infants: