DCD-0335A
11/00
DIVISION OF CHILD DEVELOPMENT
SUBSIDIZED CHILD CARE INPUT FORM FOR DPI CERTIFIED CHILD CARE PROGRAM
PART A: TO BE COMPLETED BY LEA Coordinator
(1) (
) CHANGE (
) TERMINATION
(2) HOURS OF OPERATION
(
) FULL-TIME (Holiday-Snowday-TWD) ____hrs. (
) SUMMER ONLY ___hrs.
( ) PART-TIME Before school ____ hrs. per day. After school ____ hrs. per day.
(3) SCC ID NUMBER
(4) EFFECTIVE DATE
M
M
D
D
Y
Y
(5) NAME OF SCHOOL SITE
_____________________________________________________________________________________________
(6) MAILING ADDRESS
______________________________________________________________________________________________________
(STREET)
_________________________________________________________________
(CITY)
(STATE)
(ZIP CODE)
(7) COUNTY NAME
__________________________________________
(8) DIRECTOR’S NAME __________________________________________________________________________
(9) PHONE NUMBER
(10) LOCATION ADDRESS
( IF DIFFERENT THAN MAILING )
(______) _______ - ___________
___________________________________________________________________
(11) SCHOOL SYSTEM NAME (OWNER)
_________________________________________________________________________________
(12) SCHOOL SYSTEM MAILING ADDRESS
______________________________________________________________
( STREET)
_______________________________________________________________
( CITY )
( STATE )
( ZIP CODE )
(13) APPROVED (Certified) 1
2
3
SHIFT
SHIFT
SHIFT
ST
ND
RD
ENROLLMENT
FROM
-
THRU
(14) AGE RANGE:
_____ yrs. _____ yrs.
(CAPACITY)
(15) RATES CHARGED FOR PRIVATE-PAYING CHILD CARE
FULL-TIME WEEKLY $ _______
BEFORE SCHOOL $ ________ wkly
AFTER SCHOOL $ ________
wkly
OR
OR
FULL DAY $ ________
BEFORE & AFTER SCHOOL $ ________ weekly rate
(16) INITIAL REGISTRATION FEES
(17) ANNUAL REGISTRATION FEES
(18) TERMINATION DATE
$_________ ___ ___
$_____ ___ ______
M M D D
Y Y
(19) OTHER CONTRACTING COUNTIES
PART B: TO BE COMPLETED BY DCD
PROVIDER NUMBER
RATE TYPE
CATEGORY
RATES EFFECTIVE
(N, C )
B
FROM
TO
FACILITY TYPE
1 / 5
M M D D
Y Y
M M D D
Y Y
MAXIMUM PAYMENT RATES
RATE GROUP
100% MONTHLY
UP TO 75% MONTHLY
UP TO 50% MONTHLY
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