Family Child Care Provider Registration Form
Fill out the following form to register your family child care with Child Care Connection.
Program Name:
First Name:
Last Name:
Address (Location):
Address (Mailing):
City:Zip Code:
Telephone:Fax:
Email:Website:
License #:
Expiration Date: Total Capacity:
Program #: Year First Licensed:
Directions, what are you located near, any landmarks?
Ages Served:
Schedule: Full Time Part Time
Hours and Days of the week the program is open:
Sunday:
Monday:
Tuesday:
Wednesday:
Thursday:
Friday:
Saturday:
Yearly Schedule:
Year Round School Year Only Summer Only
Are you a Child Care Food Program Member?Yes No
Do you provide transportation? If yes, explain:
For school age care, schools served. What school(s) would a school age child living in your home attend? What school(s) are walking distance from your home? Do you transport from any schools?
Total number of vacancies:
Please list your full time and part time openings by age group:
Age Group
Please list your full time fees according to age group:
Please list your part time fees according to age group (if applicable).
The State of Massachusetts is trying to establish whether or not there is a problem among providers in regards to health insurance. Please help us by answering the following questions.
Is Health Care something you would like help with? Yes No
What type of health care coverage do you have?
Family Plan Individual Plan Children Only None
How was your health care coverage obtained?
Spouse's/Ex-Spouse's plan Chamber of Commerce
On my own Other group plan Cobra Mass Health
Second job/another employer Family Child Care System
VA Medicaid Medicare
Do you offer a sibling discount? Yes No
Do you accept vouchers? Yes No
Please check off any applicable education:
High School Diploma/GED Associate's Degree
Bachelor's Degree Advanced Degree
Early Childhood Related College Courses
Some College Courses
My degrees are in:
I have experience with the following special needs:
Hearing impairment Medical impairment
Physical disability Learning disability Speech/Language
Emotional/Social/Behavioral Developmentally delayed
Special circumstances
I have the following training and/or experience with the above special needs:
Own child(ren) Relative's child(ren) On-the-job training
Workshops/CEU's Undergraduate work EI program
Public schools Other
Languages besides English? Please list:
Are you a non smoker?Yes No
Do you have a smoke-free home? Yes No
Please list birth dates of your own children:
I live in a Single Family Home Multi-Family Home
Is there anything about your program that you would like us to know or do you have any questions for us?
To contact an information and referral specialist call 508-757-1503 or provider@cccfscm.org.
Thank you for taking the time to complete this form. Please click the Submit button to send us your information.
