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This Provider Intake Form is available to all registered/licensed child care providers in order to update our files. This information will assist us in providing referrals to families requesting child care. Please complete all of the information on this form and submit it as soon as possible. This form can be completed whenever there is a change or vacancy in your program. You may call Alice Rosado at 845-425-0009 x495 if you have any questions.

Contact Information
Please list all schools that you are on the bus route for
Additional Details
Number of vacancies for infants
Number of vacancies for toddlers
Number of vacancies for 3-5 Year Olds
Number of vacancies for 5-10 Year Olds
Language(s) spoken by staff
Check all that apply
List any other languages spoken by your staff
Is your program located near public transportation?
Do you provide transportation?
If you do provide transportation, please check all that apply
Medication - MAT
Does your program include?
Check all that apply
Environment
Please check all that apply
Meals
Check all that apply
Meals (continued)
Check all that apply
Philosophy
Check all that apply
Financial Assistance
Check all that apply
Policies
Check all that apply
Safety
Check all that apply
Special Needs
Check all that apply
Training
Check all that apply
Experience
Check all that apply
CDA Credential
Check all that apply
Program Accreditation
Are you working on Accreditation and part of the Quality Child Care Campaign?
Education
Check all that apply
Affiliation
Additional Care Services
Check all that apply

Schedule of Program

Start Time/End Time; ex. 9am-5pm
Start Time/End Time; ex. 9am-5pm
Start Time/End Time; ex. 9am-5pm
Start Time/End Time; ex. 9am-5pm
Start Time/End Time; ex. 9am-5pm
Start Time/End Time; ex. 9am-5pm
Start Time/End Time; ex. 9am-5pm
Schedule (continued)
Check all that apply

Fee Schedule

Rate per hour or week
Rate per hour or week
Rate per hour or week
Rate per hour or week
Rate per hour or week
Rate per hour or week
Additional Fees
List any other fees that you may charge families