Provider-Fairfax County Child Care Central Website Application Form Page 2
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1
2Schedule
(hours and days of operation as well as alternative schedules you offer)
Hours of operation:
Open ____________ a.m.
Close ____________ p.m.
Schedule Options:
______ Full-time only
____ Full-time and Part-time
______ Part-time only
Days of Operation:
______ Sun
____ Mon
_____ Tue
____ Wed
_____ Thur
______ Fri
_____ Sat
Care Level and Options
Minimum Age you would enroll _____________ mos/yrs
Maximum age you would enroll ____________ mos/yrs
Alternative options you are willing to consider:
_____ before school
_____ weekend care
______shift/rotating week
_____ after school
_____ holidays/vacation
______summer only
_____ before/after preschool
_____ occasional/back-up
______school year only
_____ extended hours
_____ mornings
______year round
_____ evening care
Describe any other schedule options you offer: _______________________________________________________________
Special Services
Do you have any experience or training in the care of children with special needs ______ Yes
________ No
Check if you have experience or training to provide the following types of special care
(please check where appropriate):
_____ Adaptive/special equipment
_____ Dispense medication
___Catheter, g-tube
_____ Downs Syndrome
_____ Allergies
_____ Emotional/learning disabilities
_____ Apnea monitor
__ ADHD/ADD, challenging behaviors
_____ Autism
_____ Nebulizer
_____ Asthma/respiratory conditions
_____ Physical Impairments (hearing impaired
motor
,
_____ Cerebral Palsy, neurological or seizure disorder
impairments, visually impaired)
_____ Development delay (language/speech delay)
_____ Physical or occupational therapy
_____ Diabetes
_____ Special diets
Are you willing to provide care for mildly ill children? (colds, ear infection, fever, etc.) ______Yes ______No
Language
Please list the languages you speak:
_____ English
_____ Punjabi
_____ French
_____ Spanish
_____ Farsi
_____ Vietnamese
_____ Hindi
_____ Arabic
_____ Tagalog
_____ Urdu
_____ Bengali
_____ Other ____________________
Can you use sign language? ______ Yes _____ No
Transportation
(Y or N)
Do you provide transportation from child’s home to your care? ____
Do you provide transportation to child’s school? _____
Do you provide transportation from your care to child’s home? _
___
Do you provide transportation from child’s school? ___
Signature
Date
By signing this application to become part of the Child Care Central Database, I understand that information about my program
will be made available to the public through the Office for Children’s Child Care Central Website and on listings requested by
parents. I also understand that the Office for Children reserves the right to remove a child care program from the Child Care
Central Database.
Please call Community Education and Provider Services at (703) 324-8100 with any questions.
FAIRFAX COUNTY OFFICE FOR CHILDREN
th
12011 Government Center Parkway, 8
Floor Suite 820
Fairfax, VA 22035-1104
Fax: (703) 653-1302
For Office Use Only
CCMS # ___________________________
Map Code
______________
Application Received _________________
Date entered into CCMS ____________________
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