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Provider Intake Form

FREE Marketing for your child care business!
Whether you are Exempt, Registered or Certified; Family or Center based.
Child Care Resource Network links parents looking for child care to providers that best match what they need. Parents receive several profiles at a time that include providersí first names, phone numbers, and defining information about what each child care program looks like.
We will contact you every three months to see if you have current vacancies and once a year to make sure all your information is up to date. Or you are welcome to contact us. If you have any questions about this or other services or how to complete the form please contact Lorena at 842-2610 or
Please fill out the form below as completely as possible and click the submit button at the bottom of the page.
* First name 
* Last name 
Business Name 
* Street address 
First started care (approx. ok) 
* City, State, ZIP 
* Primary phone number (This is the number given to parents) 
2nd phone number 
Fax number 
Mailing Address (if different), City, ZIP 
Previous name used 
Email address 
To support parents looking for child care, limited information about your child care business wil be included online at the state Childcare Resource & Referral site, If you do not want your information included you must check the following statementI Do NOT give permission to be included for online referrals. 
* License TypeRegistered (RF) Certified (CF or CC) Exempt (NOT licensed by CCD) 
License number (If you are licensed, this is required.) 
Expiration date 
* Do you offer preschool or kindergarten readiness?Yes No 
If you are a home-based provider, how many of your own children 
* Total Licensed Capacity (Maximum legal capacity minus your own children) 
* Total desired capacity 
* Total Vacancies (Current openings) 
* Age range accepted in care (From - years, months, weeks, To - years, months, weeks) Six weeks to 13 yrs. Up to 18 years if you accept children who need care due to a disablility. 
* Transportation Available (check all that apply)NO transportation provided
Near school bus
Near public transportation
Walking distance of school
Transports to/from elementary school
Transports to/from sports/activities
Transports to/from multiple schools
Transports to/from kindergarten Transports to/from preschool
Transports to/from child's home
* Language (check all that apply)English Spanish Sign Language Other 
Other language spoken 
* Name of elementary school(s) you serve 
* Referrals to parents are based on the hours and days you report you are open. Days of the week you are open (select all that apply)Sunday Monday Tuesday Wednesday Thursday Friday Saturday 
* Hours (list actual time from and to; or 24 hour care) 
Will you also offerOccasional early morning
Occasional evening
Occasional overnight
Occasional weekend
Flexible am
Flexible pm
* Care arrangements (check all that apply)Full time
Part time
Full year
School year only
Summer only
Drop in
Open holidays
* List your rates for all the ages you accept (infant, toddler, preschool, school age - school year and summer) List the rates as matches how you plan to charge for care. Full time, part time, hourly, daily, weekly, and/or monthly. 
Environment (check all that apply)No smoking on premises No pets at all No cats No dogs Pets separate from children Completely fenced yard No TV Monitored TV Outdoor play area Covered outdoor play area Outdoor play structure 
Additional FeesRegistration fee Deposit Extra charge for meals Materials/Book fee Activity fee Transportation fee 
Meals (check all that apply)USDA food program Provides breakfast Provides lunch Provides dinner Provides snacks Parent must bring meals Special meal requests accommodated Breastfeeding supported 
PhilosophyMontessori Waldorf Religious curriculum 
* Willing to accept DHS?Yes No 
Financial Assistance (check all that apply)DHS listed Qualified for DHS enhanced rate Multi-child discount Offers sliding fee scale Rates negotiable Offers scholarship Parent coop  
Policies (check all that apply)Written contract
Written policies
Liability insurance
Have backup (substitute) provider
Have references
Pay for slot whether child is in care or not
Charges late fees
Must be potty trained
Needs payment in advance
Special Skills (check all that apply)Inclusion training (disability)
Domestic violence/abuse training
Behavioral issues training
Medical support training
Diversity training (cultural)
Training (check all that apply)First aid
Food handlers permit
R/RCAN (Recognizing abuse/neglect)
Family child care overview
Exempt Provider Orientation (with the union)
Special Needs - check all that apply. Child Care Resource Network, to be in compliance with the Americans With Disabilities Act, assumes all providers will have a willingess to reasonably accomodate children with disabilities.Behavior supervision/supp(ADHD)
Diapering/toileting assistance for older children due to a disability
Nursing care
Wheelchair access/support
Diabetic care
Communications supports
Mobility assist (braces/walkers)
Physical therapy
Accessible bathroom
Asthma care
Sight impairment support
Socialization supports (Autism)
Medication monitoring
Specialized equipment
Special Needs 13-17 years of age
Seizure disorder care
Experience (check all that apply)Center care experience
Previous family child care experience
K-elementary classroom teacher
Experience with medical assistance
* Education (check highest level attained)High School diploma/GED
Some college - child related
Some college - other emphasis
Associate degree - child related
Associate degree - other emphasis
Bachelors - child related
Bachelors - other emphasis
MA/MS or PhD
Some High School
Accreditation (check all that apply)NAFCC - National Assoc. of Family Child Care
NAEYC/NAECP - National Assoc. for the Education of Youth Children/Academy for Early Childhood Program Accreditation
Affiliations (check all that apply)PRO - Provider Resource Organization
OACCD - Oregon Assoc. of Childcare Center Directors
NAFCC - National Assoc. of Family Child Care
OAEYC - Oregon Assoc. for the Education of Young Children
OFCNN -Oregon Family Child Care Network
OSAC - Oregon School Age Coalition
Provider Network
Stand for Children
Other provider support organization
Quality Indicators (choose one)Oregon Registry Step 1
Oregon Registry Step 2
Oregon Registry Step 3
Oregon Registry Step 4
Oregon Registry Step 5
Oregon Registry Step 6
Oregon Registry Step 7
Oregon Registry Step 8 or 8.5
Oregon Registry Step 9 or 9.5
Oregon Registry Step 10 or above
Program Structure (check all that apply)Homework assistance Scheduled activities Field trips Additional lessons Computer Organized outdoor activities 
* Briefly describe your child care business to parents with information not already provided above. Take your time and be sure to check your spelling and grammar. This statement will reflect your business to customers. 
* How did you hear about us? 

We want you to understand that Child Care Resource Network (CCRN) only makes REFERRALS AND NOT RECOMMENDATIONS! It remains the parent's responsibility to screen the child care providers who are referred by CCRN by visiting the day care home/center and asking questions. It is also the responsibility of the providers to screen parents referred to them.

I wish to become enrolled with CCRN. I understand that any information stated on this form may be released to parents seeking child care. I understand that Child Care Resource Network may request a statewide criminal record check.

In order to help CCRN keep up-to-date information on availability of child care, I agree to contact CCRN when changes occur (changes in the number of openings, full, new services, new hours, etc) in my Child Care Program.

To complete the form press the submit button below.

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Provider Intake Form
101 North Grape Street
Medford, OR 97501
Phone: 776.8590 or 800.636.7450
Fax: 541.779.2018
Email Us
Hours: 7:30 - 4:30 Mon - Fri
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