Helpline Center Child Care Resources Provider Intake Form Page 3
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5Master's Degree
I have the following: (Circle all that apply)
NAEYC Accredited (Nat. Assoc. for the Edu. Of Young Children)
(Member of NAEYC/SDAEYC/SAEYC)
Member of NAFCC (National Association for Family Child Care)
Other:
Rates:
Age Range
Hourly PT
Hourly FT
Daily PT
Daily FT Weekly PT Weekly FT Other PT
Other FT
Under 1 Year
1-2 Years
2-3 Years
3-4 Years
4-5 Years
5-10 Years
10-15 Years
Licensed Capacity Numbers and Vacancies:
Age Range Desired Capacity
Licensed Capacity
FT Vacancy
PT Vacancy
Under 1 Year
1-2 Years
2-3 Years
3-4 Years
4-5 Years
5-10 Years
10-15 Years
Please share additional information on your care below or attach a sheet about the services you provide. This will allow
parents to have a more detailed description of the care you provide:
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