Fairfax County Child Care Central Website Application Form (Page 2 of 2) in pdf

Care Level

SCHEDULE

Hours and days of operation as well as alternative schedules you offer

H ours of Operation:

Open ___________ a.m.

Close ____________ p.m.

Minimum age you would enroll __________ mos/yrs

Maximum age you would enroll __________ mos/yrs

Schedule Options:

___ Full-time

___ Part-time

Days of Operation:

___ Sun

___ Mon

___ Tues

___ Wed

___ Thurs

___ Fri

___ Sat

Alternative Options you are willing to consider:

___ before school

___ year round

___ evening care

___ after school

___ extended hours

___ weekend care

___ before/after preschool

___ occasional/back-up

___ summer only

___ holidays/vacation

___ shift/rotating week

___ before/after camp

___ school year only

___ morning

___ 24-hour

SPECIAL SERVICES

Experience or training in the care of children with special needs____ Yes ____ No

Check if you have staff with experience or training to provide the following types of special care

(Please circle where appropriate)

__ Adaptive/special equipment

__ Down’s Syndrome

(apnea monitor, catheter, g-tube, nebulizer)

__ Emotional/learning disabilities (ADHD/ADD,

__ Allergies

autism, challenging, behaviors)

__ Asthma/respiratory conditions

__ Physical Impairments (hearing impaired, motor

__ Cerebral Palsy, neurological or seizure disorder

impairment, visually impaired)

__ Development delay (language/speech delay)

__ Physical or occupational therapy

__ Diabetes

__ Special diets

__ Dispense Medication

__ Other (please specify) _________________________

Language:

Please list the languages spoken by your staff: ___ English ___ Spanish

___ Vietnamese

___ Farsi ___ Korean ___ Hindi ___Punjabi ___ Other (please specify) ________________________

ify) ________________________

Can anyone in your program use sign language? ___ Yes

____ No

TRANSPORTATION

Transportation services provided as part of your program

Do you transport children:

To/From their home to your care?

__ Yes __ No

List the elementary school(s) you are near and whether transportation is available to and/or from the school(s) and

your program. The transportation can be either by school bus or your program vehicle.

School Name_____________________________________

___ to school

___ from school

School Name_____________________________________

___ to school

___ from school

School Name_____________________________________

___ to school

___ from school

Signature

Date

By signing this application to become part of the Child Care Central Database, I understand that information about my program

will be made available to the public through the Office for Children’s Child Care Central Website and on listings requested by

parents. I also understand that the Office for Children reserves the right to remove a child care program from the Child Care

Central Database.

Please call Community Education and Provider Services at (703) 324-8100 with any questions

FAIRFAX COUNTY OFFICE FOR CHILDREN

12011 Government Center Parkway 8

floor, Suite 820

Fairfax, VA 22035-1104

Fax: (703) 324-3925

For Office Use Only

CCMS # ______________________________

Map Code _______________________

Application Received _____________________

Date entered into CCMS ____________________

Fairfax County Child Care Central Website Application Form Page 2

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