Provider first Name and last Name:

First Name
Last Name

Business Name: (Optional)

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 school:

Primary phone number (on site):

Work Phone

Secondary phone number:

Work Phone

Fax phone number:

FAX

Email address:

E-mail

Website (business):

URL

Total desired capacity (actual # of children you'll accept at one time):

Total current vacancies (do not include future vacancies):

Please check all of the Elementary Schools that you serve:

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

For the schools that you serve (check all applicable):

Transportation is provided     Walking distance to school  

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

Which 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      

What schedule of care do you currently have 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

What type of schedule do you accept:

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

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:

CCL New Provider Training                                     
UC Davis Training                     
Child Care Initiative Project (CCIP)
CCFP Workshop                        
Workshop -- CCL                 
Workshop Other                        
ECE Conference                      

Please select all that apply to your staff:

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

Have you participated in the Child Care Initiative Project:

Current CCIP Participant
Level 1
Level 2
Level 3
Level 4
Past CCIP Participant
Request CCIP information

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

Montessori         		
Religious          
Kindergarten       	
Academic         
Child Development  	
Parents CO-OP      
High Scope         		
Other   
   

Are you a member of the Child Development CORPS? Yes No

If Yes, please state your level and tier?

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