"FY 2010 Provider Participation Agreement"
Submit by Email Print Form 780 West Main Street Avon, MA 02322 Phone: 508-559-1666 Fax: 508-583-3808 Email: firstname.lastname@example.org Web: http://www.selfhelpinc.org/CommunityPartnerships/index.html FY 2010 Provider Participation Agreement This agreement is made between: Program Name Herein after referred to as the Provider And with a usual place of business at Street Address City State Zip AND Self Help Inc./Community Partnership for Children Program name Self Help Inc./Community Partnership for Children, herein after referred to as SHI/CPC. Self Help Inc. is the “lead agency” grantee of the CPC Program. This program is supported by a grant from the Massachusetts Department of Early Education and Care (EEC). The material within this agreement does not necessarily reflect the views or policies of the Massachusetts EEC, the federal Government or the lead agency. The activities are to be financed under the MA EEC project for the Community Partnerships for Children Program. The Provider Agrees to: 1. Be a partner in creating a quality system of early education and care. 2. Pursue and maintain a program that is high quality. 3. Be an active participant on the Self Help Inc./CPC Council to help shape services and programs for the local community. 4. Participate in data collection or other projects as required by the funding source, EEC. Self Help Inc./CPC Agrees to: 1. Provide Support and Resources for the program to achieve and maintain quality. 2. Provide Information and Support to the families served by the program. 3. The level of service to be provided is completely dependent on funding available. This agreement will be in effect from July 1, 2009- June 30, 2010 unless one party submits in writing a wish to absolve the relationship/agreement. Self Help Inc./CPC Authorized Rep. Program Authorized Rep. CPC Director Title Title Date Date Please fill out the following Information completely. The information you provide us will assist us in providing you with the best service we can. Program Information Program Name: Director’s Name: Site Address: City: Zip: Mailing Address (if different): Phone #: Fax #: Email: Council Contact: Specialist Contact: (Please check one) Public School Center-based Family Child Care (please check one) independent system Current EEC License #: (please attach copy of license) License Expiration: Accreditation Status (PLEASE CHECK all that apply and fill in expiration/and attach copy of credential): NAEYC Expiration: CDA Expiration: NAFCC Expiration: Degreed Family Childcare Provider (Indicate level of degree, A.A., B.A, MA and area of study): None of the above Classroom Site Information # infant/toddler classrooms: # of infant/toddler children: # infant/toddler STAFF: # preschool classrooms: # of preschool children: # preschool STAFF: # kindergarten classrooms: # of kindergarten children: # kindergarten STAFF: # afterschool classrooms: # of afterschool children: # afterschool STAFF: Educator/Teacher Information Total Number of Teachers/Educators at Site: Please indicate the # of Teachers/Educators at each Level Listed (count each teacher only once at their highest level: High School/GED: Center Based CDA: Associates Degree: Bachelors Degree: Masters Degree: Other: Program Funding (please indicate all types of funding received) EEC Vouchers EEC Contracted Slots DSS/DTA Slots EEC UPK Assessment/Planning Grant Funding EEC UPK Quality Grant Funding EEC License Plate Quality Grants Other: None of the above Assessment Information Please Indicate the Assessment Tools Used in your Program: Creative Curriculum Developmental Ages And Stages Other: Continuum For Ages 3-5 High Scope Child Observation Record The Work Sampling System None Program Name: Professional Development Needs Please indicate the Content Areas of Professional Development that your Program and Staff would be interested in and the training level you would be interested in (check as many that apply): CONTENT AREA TRAINING LEVEL Understanding Growth & Development of Children 2 hour workshop CEU Training Assoc. Level Course Bachelors Level Course Masters Level course Online Guiding & Interacting with Children 2 hour workshop CEU Training Assoc. Level Course Bachelors Level Course Masters Level course Online Partnering with Families & Communities 2 hour workshop CEU Training Assoc. Level Course Bachelors Level Course Masters Level course Online Health, Safety & Nutrition 2 hour workshop CEU Training Assoc. Level Course Bachelors Level Course Masters Level course Online Observation, Assessment & Planning 2 hour workshop CEU Training Assoc. Level Course Bachelors Level Course Masters Level course Online CONTENT AREA TRAINING LEVEL Program Planning & Development 2 hour workshop CEU Training Assoc. Level Course Bachelors Level Course Masters Level course Online Professionalism & Leadership 2 hour workshop CEU Training Assoc. Level Course Bachelors Level Course Masters Level course Online Other (please list any and all additional content areas or 2 hour workshop CEU Training Assoc. Level Course topics you would be interested in for PD): Bachelors Level Course Masters Level course Online 1. 2. 3. 4. Support Services-please indicate any/all services you may be interested in for your program, staff, families Program Services Accreditation/NAEYC Curriculum Kits Computer Skills MA Prog Standards & Guidelines Center-Based CDA Legislator Readings Universal Pre-K (UPK) NAFCC (Family Providers) Senior Center Volunteers Classroom Observations/Support CDA (family providers) other: Staff/Teacher Services MA Prog Standards & Guidelines Computer Skills Literacy in the Classroom On Site Workshops/trainings Accreditation/NAEYC other: Off Site Workshops/Training Career Counseling/Development other: Classroom set up/environment Kindergarten Transition other: Parent/Family Services Career Counseling/Development Parent Resource Library Info./referral to other services Child Development Workshops Behavioral Strategies for Home Access to Childcare Financial Transitioning to Kindergarten Parent Child Play Groups Assistance Waitlist Support Group Literacy/Language Play Groups other: