Child Care Provider Information Form

Collects experience, certifications, availability, and rates from people who offer child care services.

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Provider's Full Name

Nombre

Apellido

Email Address

Phone Number

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Do you have a valid child care license?

Yes No

How many years of experience do you have in child care?

What age group of children do you specialize in caring for?

Infants Toddlers Preschoolers School-age children

What is your preferred child care setting?

In-home Daycare center Family child care Other

Are you CPR and First Aid certified?

Yes No

Do you have any specialized child care training or certifications?

Do you have any pets in your home?

Yes No

If yes, please provide details about your pets.

What is your availability for child care services?

Please provide details about your child care rates and payment terms.

Do you have references from previous child care clients?

Yes No

If yes, please provide contact details for your references.

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