Director First Name and Last Name

First Name
Last Name

Center Name:

Affiliated Business Name (i.e. Church, City):

Location:

Unit#

City:

Livermore Pleasanton Dublin Sunol Select

Zip Code:

94550 94551 94566 94588 94568 Select

Nearest major cross streets (i.e. Murdell & Stanley):

Nearest Public Elementary school:

Primary phone number (on site):

Work Phone

Secondary phone number (off-site administrative):

Work Phone

Fax phone number:

FAX

Email address:

E-mail

Website (business):

URL

Total current vacancies (all age groups - do not include future vacancies):

What age group do you currently have openings for:

Infant-Newborn to 2 years old         	Preschool 2 to 5 years 11 months old  
Kindergarten                          	School-age 1st grade and up      

Do you have an infant waiting list  Yes No Select  

                                                             
What schedule of care do you have current openings for:

Full time (<30 hours)
Part time (>30 hours)
Both

What time do you open:

-- hh:mm:ss am/pm

What time do you close:

-- hh:mm:ss am/pm

Select your program schedule types:

Full time (<30 hours)
Part time (>30 hours)
Both

Select the correct schedule for your program:

Full year                   
School year  
Summer only  

Do you provide any of the following:

Drop in                             Overnight  	       After school care      Weekends        
Evening (after 7pm)          Before school care       Rotating                   Open school holidays

Please check all of the Elementary Schools that you serve:

Please list any additional middle schools, private schools or preschools you serve:

What languages do your staff speak fluently/conversationally: (check all that apply)

Which meals do you serve:

Breakfast     	AM snack      Lunch         PM snack    
Dinner        	Special diet  None         
 

Have you or your staff participated in any of the following:

                                                           
Workshop -- CCL                 
Workshop Other                        
ECE Conference                      

Please indicate the number of your staff at each education level:

Academic Units - 6 (ECE)   
Academic Units - 12 (ECE)  
Academic Units - 18 (ECE)  
Academic Units - 24 (ECE)
AA (ECE)                   
BA (ECE)                   
AA (Other)                 
BA (Other)  

Please indicate the number of your staff that have the following:

       
Child Development Permit   
ECE Certificate            

Would you like to be involved with Child Care Advocacy efforts?

Receive e-mail action alerts  
Write letters                 
Make phone calls                   
Visit legislators
No thanks         

Does your program include any of the following curriculums or programs:

Montessori         		
Religious          
Kindergarten       	
Academic         
Child Development  	
Parents CO-OP      
High Scope                          
Other (fill in)           

Does your center have a non profit status:YesNo Select

Does your center have any of the following contracts:

Head Start       		          
CDE/State Preschool       	      
CDE/All but State Preschool 		    
Other Public contracts  		

Is your Center accredited by any of the following

NAEYC        		   
CAEYC       	  
CDA
NSACA
Other (fill in)       	    
        		

Is your center affiliated with any of the following:

Public School  		College     		LARPD 
Private School       	City of Livermore         	Parks and Recreation Dept.   
Church  		City of Pleasanton   
Employer         		City of Dublin           

Are you or your staff members of the Child Development CORPS?    
Yes	No

If "N0", would you like more information about the Child Development CORPS?    
Yes	No

Please indicate the number of staff who are:

   
Professional Growth Advisor       	  
Past CORPS member

Please report the level and tier for each Child Development CORPS Member on your staff:

Name: Level:Tier:
Name: Level:Tier:
Name: Level:Tier:
Name: Level:Tier:
Name: Level:Tier:
Name: Level:Tier:
Name: Level:Tier:
Name: Level:Tier:
Name: Level:Tier:
Name: Level:Tier:
Name: Level:Tier:
Name: Level:Tier:
Name: Level:Tier:
Name: Level:Tier:
Name: Level:Tier:

Special Needs Questions:


1)  Realizing the ADA Law requires you to serve all children including those who may have special
    needs, do you or any of your staff, have any of the following in relation to caring for children with
    special needs (child all that apply)

Training    
Academic Coursework  
Child Care Experience
Workshop 
Related Degree
Personal Experience

2) Please check any of the following categories you and/or your staff have training or experience with
    (check all that apply)

Behavioral/Emotional/Psychological 
Special Health/Medical Needs 
Communication/Language
Physical Disability 
Visual/Hearing
Development Delays
Developmental Disability
Learning Disability
Requires Special Equipment/Dietary/Med. Needs
Other Illness or Disorder

3) Are you currently caring for children with a disability/special needs? (as noted in questions #2)
    Yes	Yes, not diagnosed	No

4) What type, or types of disability/special needs does the child(ren) have and what is the corresponding age of the c  child? List primary disability first. (if applicable):

Child                Type of Disability/Special Needs                                           Age

Child 1:	 	
Child 2:	 
Child 3:	 
Child 4:	 
Child 5:	 

5) If training was provided, what topic would you be interested in?

For more information, support or assistance in answering these questions, please contact the Child Care Links Inclusion Coordinator at (925) 417- 8733