New Provider Registration Form Please fill out the following form to REGISTER your program with us. To better serve you please fill in ALL fields. ALL fields marked RED are required to submit this form. If you are already registered with us, please use this form to update your information. If you have trouble filling in this form or need further assistance, please call us at 580-548-2318, 580-548-2285, 1-800-401-3463 or click here to email us. If it is a technical (web site) issue you can email the webmaster here

C H I L D C A R E F I N D E R . O R G

Contact Information Today's Date: First Name: Last Name: Street Address: City: Zip: County: Primary Phone: Secondary Phone: Fax Number: Email Address: Website Address: Business Name: (centers only) Major Cross Streets: 1st 2nd Type of Child Care Program:  Child Care Center  Family Child Care Home Large FCC Home  Pre-School/MDO  Drop In Center Summer Camp  Before/After School Only  Nanny  Head Start  First Start Do you accept Drop-In care?  Yes   No Mailing Address (if different than above): City: Zip: County: Contact Name (if different from above):  License Information DHS License Number: (K8) License Type:  Center  Drop-In  Family Child Care Home  Part Day  Exempt   Capacity: Licensed Capacity: Accepted Age Range of Children: (example 1 week to 12 years) From:  Youngest To:  Oldest Funding (check only if you receive this type of funding):  Head Start  State Pre-K Funding Transportation (check all that apply):  Transportation Provided  Walking Distance to School  Near Public Transportation  Transportation to/from School  Transportation to/from Home  Close to School Bus Stop  Close to City Bus Stop  None Schools served (if any, list them all): Languages (check all that are fluently spoken):  English  ASL (sign)  French  Laotian  Spanish  Vietnamese  Arabic Current Star Level:  One Star   One Star Plus   Two Star   Three Star Accreditation:  ACSI    COA    NAA    NECPA    NAEYC    NAFCC Do you accept DHS Subsidy?  Yes   No When do you offer Childcare? Hours of Care: Days of Week: Private Pay Clients - Rate Information: Age of Child Daily Full Time Weekly Full Time 0-12 months 13-23 months 24-35 months 36-47 months 48-60 months 61+ months DHS Subsidy Clients - Rate Information: Age of Child Daily Full Time Weekly Full Time 0-12 months 13-23 months 24-35 months 36-47 months 48-60 months 61+ months Environment: (check all that apply):  Wheelchair Accessible  No Pet  Smoke Free Meals: - Does your program participate in the USDA Food Program?  Yes  No Special Needs (check all that apply):  Behavioral  Developmental  Medical  Physical Education (check as many that apply to you):  Administrators Credential  CDA/CCP Credential  Associate's Degree - Child Related  Associate's Degree - NOT Child Related  Bachelor's - Child Related  Bachelor's - NOT Child Related  CDA/CCP Currently Enrolled  Certificate of Mastery  Master's Degree Child Related  Master's Degree Not Child Related  Center Information  Please fill in the section that applies to you:  Section A - if you are a 'Family Child Care Home'  Section B - if you are a 'Child Care Center' Section A Family Care setting?  House  Apartment  Townhouse  Mobile Home  Duplex  Non-Residential   Please complete the following Demographic information: Are you?  I choose not to answer  Spanish/Hispanic/Latino  Mexican/Mexican American, Chicano  Puerto Rican  Cuban  Other - please specify    What is your Race?  I choose not to answer  White  African American  American Indian/Alaskan  Asian Indian  Native Hawaiian  Chinese  Filipino  Japanese  Vietnamese  Other Asian  Guamanian or Chamorro  Samoan  Other Pacific Islander  Other   Do you speak a language other than English at home?  No      Yes - please specify    Section B  I choose not to answer the questions below Please list the number of persons on staff who are Spanish/Hispanic/Latino:  Mexican/Mexican American, Chicano  Puerto Rican  Cuban  Other - please specify    Please list the number of persons on staff who's race is:  White  African American  Asian Indian  Native Hawaiian  Guamanian or Chamorro  Samoan  American Indian or Alaskan Native - Tribe   Chinese  Filipino  Japanese  Vietnamese  Other Asian   specify   Other Pacific Islander   specify   Other Race   specify    Number of persons on staff who speak a language other than English at home What Language/s? Thank you for taking the time to complete this form. Please enter the code shown in the image below and then click the 'Submit' to send us your information.

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