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Use This Form to Update Your Child Care Information This form will be submitted using your PC's email account. It will not work with an online email account. If your PC is not configured to send email you can print out the form and fax it, mail it or call a Child Care Specialist to take your update. Middlesex Phone 732-324-4357, Fax 732-324-0690 Somerville Phone 908-927-0869, Fax 908-927-9653
Middlesex County		Somerset County
Provider Information Business Name Director / FCC Provider Name Location Address (Number & Street or P.O. Box) City, State & Zip Mailing Address ( if different than location) City, State & Zip Primary Phone Secondary Phone Fax E-Mail Address Website
Licenseing Information Operating Cap Licensed Cap Tax ID/SS# EIN # Lic. ID # Expiration Date Full Time Vacancies Part Time Vacancies Ages Served From To		Days of Operation Monday Tuesday Wednesday Thursday Friday Saturday Sunday Hours of Operation from To Do you have extended hours? Yes No
Type of Care that you Provide Child Care Center Family Child Care Home Preschool Program School Age Program located in a school not in a school Head Start Faith Based Camp			Philosophy Developmental Emergent Curriculum Religious Mixed age Other
Please check that which apply: Open Full Year School Year Summer Only
Do you provide any of these special services? Drop-in Care Temporary/Emergency Care Sick Care Evening Over-night Weekend Care Summer Care School Holidays / Snow Days Respite Care		Financial Assistance: check all that apply Fee Negotiable NJ Cares for Kids (NJCK) Work First NJ (WFNJ) Subsidy Discount Employer Discount Contracted Child Care Center Multi Child Discount Scholarships Sliding Scale Other
Experience Serving Children with Special Needs
ADHD/ADHD Hearing Learning Disability Medically Fragile Wheelchair Equipment	Asthma/Allergies Physical Disability Emotional/Behavioral Tube Feedings/IVs Blood-borne diseases	Autism Speech Monitor Seizures	Visual Developmental Delay Diabetes Other
Accreditation National Association For the Education of Young Children (NAEYC)
Affiliations NAEYC Other
Training CPR First Aid CDA CCP ECE Training Enhanced Networks Advanced Degree RN /LPN		Environment Smoke - Free No Pets Indoor Pets Outdoor Pets Fenced Yard Own Children in Care Separate Child Care Area Outdoor Play Equipment Swimming Pool Wading Pool Diapering Facilities Air Conditioning
Meals Served Breakfast Morning Snack Lunch Afternoon Snack Dinner Child Care Food Program Special Diet Child Provides Own	Child Care Fees Infant Daily Infant Weekly Infant Monthly Toddler Daily Toddler Weekly ToddlerMonthly Preschooler Daily Preschooler Weekly Preschooler Monthly School Age Daily School Age Weekly School-Age Monthly Additional Fees Registration Fees Late Fees Security Deposit
Population Information Children Served for each Age Group Infant Toddler Preschooler School Age School Age Information What schools do you serve? Do you provide before /after kindergarten care? Do you provide before / after school care? Are you on a bus route for that school?
Transportation Transportation offered by you or your center Near Public Transportation	Language American Sign Language Chinese English French German Hebrew Italian Japanese Russian Spanish Vietnamese Other	Policies Written Parent Handbook Written Contract Child Absense Allowance Provider Absense Allowance Accident/ Liability Insurance Late Fee Other	Safety Video Monitors Web Cam Password / PassKey Admittance On-site Nurse Fire Extinguisher Carbon Monxide Alarm Intercom/Door Buzzer
Registration Number
What You can Do to Help Resource & Referral Provide Better Services Thank you for helping us better serve you and our community. Comments


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