Mail or FAX to:
Family Connections
of Lane and Douglas Co.
4000 E 30th Avenue 
Eugene, OR 97405		Family Connections of Lane and Douglas Co.     	For Office Use Only	
			Provider Record	     	
		CHILD CARE PROVIDER INTAKE FORM	Date Added	     	
		(541) 463-3954  (800) 222-3290  FAX (541) 463-4724	Staff Initials	     	
This form can be filled in right into the document. You can save and e-mail as an attachment to familyconnections@lanecc.edu or print and mail or fax. See address and fax number above.	
       First Name:                	Last Name:      	
Business Name:      	Date first began care (approximate is ok):                   	
Street Address:	     	City	     	State	     	Zip	     	
Mailing Address (if different)	     	City		State	     	Zip	     	
	
Primary Phone:         	Fax Phone:         	Cell Phone:     	
Confidential Information :  Last 5 digits of  SS#             Date of Birth:      	
Website address:     	Email:         	
License
Info	Registered or Certified	License #	     	Expiration Date:	      	
	Exempt (not licensed with the Child Care Division)	
Accepts Children  FROM AGE          weeks   mo.   yrs		TO AGE         weeks   mo.   yrs	
  Desired Capacity:     
Current Openings:     
For licensed family child care – Do not count your own children   	
What Elementary school does / would your children attend?      	
Ethnicity Mark the ONE you most relate to:	Caucasian (White) 	Hispanic/Latino(Chicano)	Native American/Alaskan 	
	Asian-Indian	Black (African American)	Hawaiian-Pacific Islander 	
If transportation is provided what schools will you transport to/from?     	
 Near School Bus	Walking Distance to School	Near Public Transportation	
  Transports to/from Designated Area School	 Transports to/from Preschool	 Transports to/from Kindergarten	
  Transports to/from Sports/Activities	 Transports to/from Multiple Schools	 Transports to/from Child's Home	
Primary Language:        	Other Languages spoken      	
Extended Hours Offered (mark all that you are willing to consider or accept)	
Early morning (starting between 3 am and 5:59 am)	Evening (after 6:30 pm)	Overnight (at least between 10 pm and 3 am)	
Weekend (regular care on Saturday and/or Sunday)	Occasional early morning	Occasional evening	
Occasional overnight	Occasional weekend 	Flexible am	
Flexible pm    Please list any scheduling conditions not listed above.	
DAYS                                                                                                                  	
Mon	Tue	Wed	Thur	Fri	Sat	Sun	HOURS                                                                                                          
 FROM         TO         	
Drop In    Temp/Emergency     Before School     After School     Rotating    24-Hour    Open Holidays	
RATES	FULL  TIME (30 or more hours)	PART  TIME (less than 30 hours)	
Under 1 yr   	        Hour  Week  Month	        Hour  Week  Month	
1 to 2 yr   	        Hour  Week  Month	        Hour  Week  Month	
2yrs to Kindergarten	        Hour  Week  Month	        Hour  Week  Month	
School Age Before/After School Care  	        Hour  Week  Month	        Hour  Week  Month	
 Registration fee	 Deposit	 Materials/book fee	 Other fees (specify what type and amount)	
 Charge for transportation	 Extra Charge for meals	 Activity fee		
 Other fees (specify what type and amount) 	

(Mark all that apply) 
ACCEPTS CHILDREN	 Full time   Part Time   Both                 	  School Year only   Summer only   Both   Any	

ENVIRONMENT	
 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	 Outdoor play structure 		

MEALS	
 USDA Food Program 	 Provides breakfast 	 Provides lunch 	
 Provides dinner	 Snacks provided 	 Parent must bring meals 	
 Special meal requests accommodated 	 Breastfeeding supported 	  	
PHILOSOPHY                         Montessori                                  Waldorf                           Religious curriculum  Reggio Emilia	
FINANCIAL ASSISTANCE             *  Please indicate one of these (not willing will be marked if Willing is not)              	
* Willing to accept DHS 	* NOT Willing to accept DHS 	 DHS listed 	
 Qualified for DHS enhanced rate 	 Multi-child discount 	 Offers sliding fee scale	
 Rates negotiable 	 Offers scholarship 	 Free to income eligible	
 Parent co-op 	 No rates - not market care 		
POLICIES			
 Written contract 	 Written policies	 Liability insurance 	
 Have backup provider (substitute) 	 Have references 	 Pay for slot whether in care or not 	
 Charges late fees 	 Must be potty trained 	 Needs payment in advance 	
SPECIAL SKILLS	
 Inclusion training	 Domestic Violence/Abuse training	 Behavioral issues training	
 Medical Support training	 Diversity training		
SAFETY	
 Infant and Child First Aid	 Infant and child CPR 	 Oregon Food Handlers Permit 	
 Recognizing/Reporting Abuse/Neglect	 Family Child Care Overview	 DHS orientation	
 Working with DHS Families	 Child Care Health and Safety (any module)		
SPECIAL NEEDS (Knowledge and or experience working with these types of needs)	
 Challenging behavior supervision/supports	 Communications supports 	 Socialization supports 	
 Diapering/toileting assistance ( past typical toilet training age)	 Mobility assistance	 Medication monitoring 	
 Nursing care (Not breastfeeding)	 Physical therapy	 Specialized equipment 	
 Wheelchair access 

	 Wheelchair accessible bathroom
	 No experience/willing to learn

 ADD/ADHD
	 Asthma 
	 Autism	
 Diabetes 
	 Hearing Impaired	 Vision Impaired
	
TRAINING	
 Dollars and Sense 	 Building Blocks – Social/Emotional (any module) 	 First by Five (any module)	
 First Connections (any module)	 Starting Points	 TRAC 	
EXPERIENCE	
 Trained as child care provider mentor 	 Center care experience 	 Previous family child care experience	
 K-elementary classroom teacher 	 Experience with medical assistance		
EDUCATION	
 High school diploma/GED 	 Some college, child related 	 Some college, other emphasis 	
 Associate degree, child related 	 Associate degree, other emphasis 	 Bachelor's, child related	
 Bachelor's, other emphasis 	 MA/MS or PhD 	 CN/CMA,LPN, or RN	
ACCREDITATION                      NAFCC           NAEYC/NAECP            NAA           CDA	
AFFILIATION (Contact Family Connections for additional information)	
 PRO 	 Other provider support organization 	 Provider network 	
 OACCD 	 OAEYC 	 OSAC 	
 NAFCC 	 OFCCN 	 Stand for Children 	
Oregon Registry	
 Step 1	 Step 2	 Step 3	
 Step 4	 Step 5	 Step 6	
 Step 5	 Step 8 or 8.5	 Step 9 or 9.5  	 Step 10 or above	
PROGRAM STRUCTURE	
 Homework assistance 	 Scheduled activities 	 Field trips 	
 Additional lessons 	 Computer 	 Organized outdoor activities	
SPECIAL REQUESTS	
 Provides transportation to kindergarten	 Has a designated child care area 	 Culturally sensitive curriculum 	
 Language immersion program	 Regular routines 	 Vegetarian 	
 Whole foods (organic) 	 No sugar		
PROVIDER PREFERENCES             Receive newsletter by email                 Receive mailings in Spanish 	
I understand that Family Connections only makes referrals, not recommendations to families. I agree to assist Family Connections in maintaining up to date information on child care availability by reporting changes in my Family Child Care home when they occur. I give Family Connections permission to release the information on this form to parents seeking child care services. In addition, Family Connections occasionally releases the names and addresses of listed providers to carefully screened child care related agencies and organizations. Unless otherwise indicated, I give Family Connections permission to release my name and address to such agencies and organizations.              
  
Signature:________________________________________________Date: _____________________