Fairfax County Child Care Central Website Application Form printable pdf download

Fairfax County Child Care Central Website Application

CENTER INFORMATION

_____ RENEWAL

Check if new address, phone number or contact person ________

Center Name ______________________________________________ Tax ID Number __________________________

Street Address ____________________________________________________________________________________

City _____________________________________ State ___VA___

Zip Code ________________________________

Phone # ____________________ Alternate Phone # ____________________

Fax #__________________________

E-mail Address_____________________________Website Address:__________________________________________

Director _____________________________________________Contact Person ________________________________

REGULATION

Which category applies to your program?

___ State License (Dates) from ____________to______________

___ Religious Exemption ___ Certified Preschool

ACCREDITATION

Is your program accredited by the National Association for the Education of Young Children? ___Yes ____ No

Other accreditation(s) ___________________________________________________________________________

AFFILIATION

Is your program affiliated with any outside organizations? ____Yes ____No

If yes, please list all that apply.

___College ___Community-based ___Employer-sponsored ___Faith-Based ___For Profit ___Independent

___Local Chain ___National Chain ___Non-Profit ___Private School ___Public Agency ___Public School

Does your program participate with the USDA Food Program? ___Yes ___No

ENVIRONMENT

Is your center near public transportation? ___Yes ___No

Is your center wheelchair accessible? ___Yes ___No

PROGRAM ENHANCEMENTS

: List the types of programs your center provides. (Check all that apply)

___Parent Co-op

___Early Intervention

___Head Start

___Infant/Toddler only

___Kindergarten/Pre-K

___Mixed Age

___Parents Day Out

___Preschool

___Private School

___School Age only

___School-based

___Summer

___Other (please specify)__________________________________

REGISTRATION FEE

$ _______

___ One-time ___ Yearly

FEES

Check all ages you serve:

Monthly Rates:

___ Infants (birth - 15 months)

$_______

___ Kindergarten (60 – 71 months)

$_______ full day

___ Toddler (16 - 23 months)

$_______

___ before and after kindergarten

$_______

___ Two-year old (24 – 35 months)

$_______

___ School age (

)

$_______ full day

72 months – 13 years

___ Young Preschool (36 – 47 months)

$_______

___ before and after school

$_______

___ Older Preschool (48 – 59 months)

$_______

Fairfax County Child Care Central Website Application Form

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