Provider Update Form

If you have any questions about filling out this form, please contact CCR&R at 888-637-4786

Please contact CCR&R Eastern if you have any questions about completing or submitting this Provider Update Form.  If you would prefer to complete a paper form, we would be happy to supply you with one.

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Please list any schools, both public and private that you service. Also, if there is additional information about this service, please tell us about it here.
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Transportaion for schools served
Check which applies to all schools you listed above. We will call for clarification, if needed.
Days and hours - please enter the start and end time for the days which care is provided. i.e. 8 am - 5 pm M-F. If the schedule is not the same every day, PLEASE list the schedule for each day.
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Schedule Information
Please check all that apply to your program
Do you keep a waiting list?
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Please list your daytime full-time vacancies for each age group on the lines below. Please take the time to also fill out the enrollment numbers. This data is collected statewide and is very important! Please include your own children, part-time, drop-in and full-time children. Please call if you have any questions about this section! If you would like to, use the space to the right to provide information you feel will help us better understand your program population structure.
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CENTERS ONLY: number of rooms for 0-11 month children
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CENTERS ONLY: number of rooms for 1 year old children
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CENTERS ONLY: number of rooms for 2 year old children
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CENTERS ONLY: number of rooms for 3 year old children
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CENTERS ONLY: number of rooms for 4-5 year old children
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CENTERS ONLY: number of rooms for Kindergarten Children
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CENTERS ONLY: number of rooms for School Age Children
Please list your daytime full-time rates for each age group below. You do not have to fill in every line. *This information is used for statistical purposes only and to help us advocate for the needs of providers. No rate information is ever identified with any individual provider.* If you would like to, use the space to the right to provide information you feel will help us better understand your rate schedule.
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Special Needs - Please check all that apply to your program. If you would like, you may add a comment in the box to the right.
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ADHD/ADD
Allergies
Asthma
Autism
Blindness/Visual Impairment
Cerebral Palsy
Developmental Delays
Diabetes
Down Syndrome
Emotional/Behavioral
Epilepsy
Feeding Tube
Hearing Impairment
Learning Disability
Mulitiple Sclerosis
Muscular Dystrophy
Orthopedic Disablilties
Oxygen Therapy
Seizures
Spina Bifida
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My program is wheel Chair Accessible
There is someone in my program at all times with a current CPR certificate
There is someone in my program at all times with a current First Aid Certificate
All adults who prepare or serve food in my program have a current food handlers Permit
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Environment - Please check all that apply to your program. If you would like to, use the space to the right to provide information you feel will help us understand your program environment.
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Child Care Enviornment
Check all that apply
Affiliation
If applicable, please check any professional organization you belong to.
Accreditation
If applicable, please check the box next to the organization with which your program accredited.
I would be willing to have a legislator visit my program
Please use this space to provide other information about your program you would like us to know or share with parents.
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