Helpline Center Child Care Resources Provider Intake Form
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5Provider Intake Form
First Name:________________________________________________________________
Last Name:___________________________________________________________
Business Name:____________________________________________________________________________________________________________
Street Address:________________________________________________________________________________
Unit #:__________________________________________
City:______________________________________________________________________________
State:__________________________________________
Zip Code:_______________________________________
Primary Phone Number:________________________________________________________________________________
Secondary Phone Number:____________________________________
Fax Number:__________________________________________________________________________
Email Address:______________________________________________
Website:__________________________________________________________________________________________________________________
License Type: (Circle all that apply)
City Registered
State Registered
Facility your daycare business is in: (Circle all that apply)
Business
House
Apartment
Duplex
Church
Accepted Age Range:
From:
years
months
weeks
To:
years
months
weeks
School Neighborhood you are physically located in:
Schools you provide transportation to or that will send a bus to pick up at your location:
Are you within walking distance to the school (4 blocks or less): Y/N
Languages Spoken in Home:
Days Care is Provided:
Day
Start Time
End Time
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
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Parent category: Legal