CHILD CARE RESOURCE AND REFERRAL SURVEY
CHILD CARE CENTER

PROVIDER INFORMATION

First Name:   Last Name:

Doing Business As:

LOCATION

Street Address:

City:   State:  NJ     Zip Code:

County: Essex    Country: USA

MAILING INFORMATION

Street Address:

City:   State:  NJ     Zip Code:

Primary Phone:   Secondary Phone:

Fax:   Website:

Email Address:

LICENSE INFORMATION

SS#: (optional)

EIN (Tax ID Number):

License ID:   Expiration Date:

CAPACITY

Total License Capacity:  5   Total Desired Capacity:

Total Vacancies:   as of

Accepted Age Range (check all those that apply to this location):
0 to 18 months: 18 months to 2 1/2 years: 2 1/2 to 4 years: 4 to 5 years:
Kindergarten: Before care: After care: Before and after care:

NOTE: Please make sure to fill out license information, capacity and accepted age range.

TRANSPORTATION

Please check all that applies to this center location.

Transportation Provided:   Walking Distance to School:   Near Public Transportation:

LANGUAGES

English: Spanish: American Sign Language: French: Italian:
German: Japanese: Vietnamese: Chinese: Hebrew:
Russian: Other:

HOURS OF OPERATION

Day Start Time End Time
Monday:
Tuesday:
Wednesday:
Thursday:
Friday:
Saturday:
Sunday:
Shift General Information
Please check all that applies to this center location.
Day: Evening: Overnight:
Weekend: Summer: Drop In:
Temp / Emergency: 24-Hour:
Open Holidays:

*24 Hour care must be documented with the Family Child Care Department. Your information must be on file who will be caring for the children while awake and asleep.
If the provider is providing 24 hour care, they cannot be sleeping while the child(ren) are sleeping. A name of the awake and supervisory adult must be listed.

RATES

Please include all that applies to this center location
Age Group Weekly Full Time Weekly Part Time Monthly Full Time Monthly Part Time
0 to 18 Months:
18 months to 2 1/2 years:
2 1/2 to 4 years:
4 to 5 years:
Kindergarten:
Before Care:
After Care:
Before and After Care:
Summer Care:
Registration:

POPULATION INFORMATION

Age Group Desired Capacity License Capacity Full Time Vacancy Part Time Vacancy Enroll
0 to 18 months:
5
18 months to 2 1/2 years:
5
2 1/2 to 4 years:
5
4 to 5 years:
5
Kindergarten:
5
Before Care:
5
After Care:
5
Before and After Care:
5
Summer Care:
5
Registration:
5

ADDITIONAL FEES

Please check all boxes that apply to this center location.

Extended Hours:   Field Trips:   Late Fees:   Meals:   Registration Fees:

Security Deposit:   Transportation Fees:

ENVIROMENT

Please check all boxes that apply to this center location.

Fenced Yard: No Diapering Facilities: No Air Conditioning:
Indoor Pets: No Pets: Outdoor Pets:
Outdoor Play Equipment: Own Children in Care: Separate Child Care Area:
Smoke Free: Swimming Pool: Wading Pool:

MEALS

Please check all the boxes that apply to this center location.

Breakfast: AM Snack: Lunch:
PM Snack: Dinner: Child and Adult Food Program:
Special Diet: Child comes with own meals:

PHILOSOPHY

Developmental: Emergent Curriculum: Mixed Age:
Religious: Other:

FINANCIAL ASSISTANCE

Multi-Child Discount: New Jersey Cares for Kids (NJCK):
Work First New Jersey (WFNJ):
Other:

POLICIES

Child Absence Allowance: Late Fee: Liability / Accident Insurance:
Provider Absence Allowance: Written Contract: Written Parent Handbook:

SAFETY

Fire Extinguisher: On-Site Nurse: Password / Passkey Admittance:
Video Monitors: Web Cam:

SPECIAL NEEDS

Please check all the appropriate boxes for this center location. This refers to the type of care your
center staff can provide regarding the below listed categories.

ADHD / ADD: Asthma / Allergies: Autism: Blood-borne Diseases:
Developmental Delay: Diabetes: Emotional / Behavioral:
Hearing: Learning Disability: Medically Fragile: Monitor:
Phyiscal Disability: Please List:
Seizures: Speech: Tube Feeding / IVs: Visual:
EPI Pen: Wheelchair / Equipment: Medication Administration:

TRAINING

Please check appropriate boxes for the training center staff has attended.

Child Development Associate:   CPR:   ECE (Early Childhood Education):

First Aid:

EDUCATION

Please check appropriate boxes for education levels achieved for center staff. This information is important
for statistical purposes, such as advocacy for higher center rates.

High School Diploma: Some College Credits: Associate Degree:
Bachelor's Degree: Master's Degree: RN / LPN:

EXPERIENCE

Please check appropriate boxes regarding related experience in the field to the best of your knowledge.

Under 1 year experience: 1 - 3 years experience: 4 - 9 years experience:
10 - 20 years experience: 21+ years experience:
Family Child Care Experience: Child Care Center Experience:

ACCREDITATION

FCCA of NJ (Family Child Care Association of NJ):

NAFCC (National Association of Family Child Care):

Other(s):

COMMENTS

Please write additional comments below.