Provider Registration Update Form Please fill out the following form to UPDATE your program with us. ALL fields marked RED are required to submit this form If you are not already registered with us, please use this form to add 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

Required Information Today's Date: First Name: Last Name: Primary Phone: Accepted Age Range of Children: (example 1 week to 12 years) From:  Youngest To:  Oldest When do you offer Childcare? Hours of Care: Days of Week: Capacity: Licensed Capacity: Openings: Current Openings: 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 Current Star Level:  One Star   One Star Plus   Two Star   Three Star Do you accept DHS Subsidy?  Yes   No How many children under the age of two will you accept in your center or home? How many openings for this age group do you have at this time?  Additional Information You need only complete this portion if any information has changed since your last update. Thank you. Street Address: City: Zip: County: Secondary Phone: Fax Number: Email Address: Website Address: Business Name: 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 Type:  Center  Drop-In  Family Child Care Home  Part Day  Exempt   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): Accreditation:  ACSI    COA    NAA    NECPA    NAEYC    NAFCC 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 Family Care setting?  House  Apartment  Townhouse  Mobile Home  Duplex  Non-Residential 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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