PARENT CHILD DEVELOPMENT CENTER FAMILY CHILD CARE by pva86757

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									                              PARENT CHILD DEVELOPMENT CENTER
                            FAMILY CHILD CARE PROVIDER APPLICATION


NAME:                                                             PHONE:                                   .

ADDRESS:                                                                                                   .

D.O.B. ________________________

How long have you lived in this area?                                                         .

Are you currently licensed for family child care by OCCS? Yes:____ No: ____

EDUCATION: High School:                                                               .

              College:                                                            .

              Additional training or certifications:                                              .:
                     :

Do you have a vehicle available during day care hours?                                    .

Which schools are near your home?                                                                          .

Other members of the household:
Name                       Age                Relationship             Hours home during daycare
                                                                                                        .
                                                                                                        .
                                                                                                        .
                                                                                                        .

Pets:                                         .
Do pets have required immunizations:              .

How did you hear about our program?                                                                            .
                                                                                                       .
                                                                                                       .

Briefly describe your child care experience below:

Position(s) Held                            Dates of Employment               Age Range of Children
                                                                                                        .
                                                                                                        .
                                                                                                        .
Other work experience including last position held:
                                                                                           .
                                                                                           .

Ages of children you would like to care for:                                                        .

Day Care Premises:
Type of home: Single family           2 Family       Apt. Building        .
Home Owner         Rent             How many floor levels are used for day care?   .

List rooms are used for day care:                                                      .
                                                                                           .
Heating system (oil, gas, electric, wood, other)                                                .

Describe the play space and equipment/materials available:
Indoors                                                                                    .
                                                                                           .
                                                                                           .
                                                                                           .
                                                                                           .

Outdoors                                                                                    .
                                                                                            .
                                                                                            .
                                                                                            .
                                                                                            .

Describe napping space for children.                                                                .
What napping materials do you currently have available?                                                 .

Describe your strengths in caring for children.                                                     .
                                                                                        .
                                                                                        .

Describe your weaknesses/ areas for growth.                                                     .
                                                                                        .

List training topics of interest to you.                                               .
__________________________________________________________________________________________
__________________________________________________________________________________________

What can you offer children in a family day care setting?                                               .
                                                                                       .
                                                                                       .

What do you like about children?                                                                .
                                                                                     .
_________________________________________________________________________________________
What do you find challenging about children?                                                                      .
                                                                                    __
_________________________________________________________________________________________.

Describe outside interests/ hobbies.                                                                          .
                                                                                                         .

Describe experiences you have had with Head Start.                                                                .
 ___                                                                                                      .

How do you think your children will respond to sharing their home/toys/parents on a regular basis with other
children?                                                                                                  .
                                                                                                          .
General health of provider and family:                                                                       .
                                                                                                          .

Hospitalizations within the past two years?(Provider or family member)                                                .
                                                                                                          .

Do you or members of your family smoke?                .


References: (List two people who are not related to you and who have seen you with young children.)

Name                                   Address                                      Telephone

                                                                                                          .
                                                                                                          .
                                                                                                          .




Please Return to:     PCDC Family Child Care
                      c/oNancy Crowell
                      86 Washington St.
                      Greenfield MA. 01301




NC
11/14/02

								
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