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Early Education Professionals

Provider Update Form

First Name:

Last Name:

Business Name:

Types of Care:

Child Care Center	Family Child Care	Preschool Program
School Age Program	Child's Home (nanny)	Ministry
Summer Program	Before/After School Only

Location Address:

Unit #:

City:

State:

Zip:

County:

Mailing Address (if different from above):

Unit #:

City:

State:

Zip:

Primary Phone:

Fax:

Email:

Website:

License:

Regulated/Licensed

Registered

Exempt
(not required to be licensed or registered under law)

EIN:

State License ID#:

Expiration Date:

Total Capacity:

Total Desired Capacity:

Total Vacancies:

as of (mm/dd/yyyy)

Ages Served:

to (please specify months/years)

School District:

Schools Served or Near Provider:

Languages Spoken in Child Care:

Transportation:

To-From Child's Home to Provider	On School Bus Route
To-From Activity	To-From Provider's to School
On Public Transportation	Walking Distance to-from School
To-From Parent's Work	No Transportation

Have you been approved by the State of Indiana to accept the CCDF Voucher?

Yes No

Hours of Care

Day	Start Time	End Time
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Care Available:

Drop-In	Temporary Emergency	Rotating
Before School	After School	24-hours
Open Holidays

Accepts Children:

Full-Time

Part-Time

Both

Duration:

Full Year

School Year

Summer Only

Rate Information:

Age Group	Age Range	Weekly Rate ($)	Daily Rate ($)	Hourly Rate ($)
Infant	0-12 months
Toddler	13-23 months
Toddler	24-35 months
Preschool	3-4 years
Preschool	5 years
School Age	Kindergarten
School Age	Before/After School

Additional Fees:

Drop-in Fee	Sick Care Fee	24-hour Fee
Transportation Fee	Meals/Snack Fee	Supplies Fee
Enrollment Fee	Activity Fee	Late Fee

Care Setting:

House	Apartment	Townhouse
Mobile home	Duplex	Non-residential
Employer	Child's home	Other

Thank you for taking time to provide us with the most up-to-date information regarding your child care business. This information will assist us in providing families in need of child care with accurate referrals to your child care and/or in understanding the needs of the community related to child care. Please note: Referrals will only be made if you have indicated that preference through your update or in other communications with our office. Additionally, referrals will only be made to providers meeting the Childhood Connections referral standards (for information on referral standards and referral policies contact our Education Coordinator or Referral Specialist at 866-693-0672). All information provided to our office is confidential and will only be shared with your consent.