Provider-Fairfax County Child Care Central Website Application Form
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1
2Provider-Fairfax County Child Care Central Website Application
Rev: 08/10/15
PROVIDER INFORMATION
RENEWAL
Check if new address or phone number ________
Name ______________________________________ Business or Tax ID
#________________________________________
(If Applicable)
Street Address ___________________________________________________________________________
City _____________________________________ State ________
Zip Code _________________
Phone # _________________ Alternate Phone # __________________
Fax #__________________
E-mail Address:____________________________ Website Address:_______________________________
Which category of regulation applies to your family child care home?
___County Permit ___Fairfax City
___Ft. Belvoir
___ State License (Dates) from ___________to______________
___ Falls Church City ____ Infant/Toddler Family Child Care System
Accreditations
(Copy of Certificate Required)
____________ NAFCC
__________ CDA
____________ Expiration Date
National Association of Family Child Care
Child Development Association Credential
Do you have pets? ______ Yes
______ No
If yes, ______ Indoors ______ Outdoors only
Do you provide a smoke free environment? ______Yes
______No
Is your home: _____ Near public transportation?
_____ Wheel chair accessible?
USDA Food Program Participation
_________Office for Children USDA Food Program
________ Other USDA Food Program
_______ None
List your neighborhood elementary school
School Name (base school) _____________________________________________________________________
C
C
C
W
S
HILD
ARE
OSTS WILL NOT APPEAR ON THE
EB
ITE
REGISTRATION FEE
$ _______
____ ONE-TIME ____ YEARLY
Weekly Child Care Rates:
Check all ages you serve and fill in rates:
___ Preschool Age Four (48 – 59 months)
___ Infants (birth - 15 months)
$_______
$_______
___ Toddler (16 - 23 months)
$_______
___ Preschool Age Five (Before School Age) $_______
___ Preschool Age Two (24 – 35 months) $_______
___ School Age: Full Time
$_______
___ Preschool Age Three (36 – 47 months) $_______
___ School Age: Before and After School
$_______
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