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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
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 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 HomeLarge FCC Home
 Pre-School/MDO Drop In CenterSummer 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 ChildDaily Full TimeWeekly 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 ChildDaily Full TimeWeekly 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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