Provider Update Form Thank you for taking a moment to update your business profile! General InformationBusiness / Provider Name*Date* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Name* First Last Email Type of care:* Child Care Center Family Child Care License ID Number*Elementary School(s) in your area that children can attend:CapacityTotal Licensed Capacity*Ages Accepted (wks / mos / yrs)*Enter the age range (eg "6 Months - 12 years") you are licensed forLicensed Infant Capacity (Birth to 12 months)*Desired Infant Capacity (Birth to 12 months)Licensed Infant Capacity 2 (1-2 year olds)*Desired Infant Capacity 2 (1-2 year olds)Licensed Toddler Capacity (2-3 year olds)*Desired Toddler Capacity (2-3 year olds)Licensed Preschool Capacity (3-4 year olds)*Desired Preschool Capacity (3-4 year olds)Licensed Kindergarten Capacity (5 year olds)*Desired Kindergarten Capacity (5 year olds)Licensed School Age Capacity (6 year olds and up)*Desired School Age Capacity (6 year olds and up)About Your ProgramTell us a little bit about your programProgram RatesPlease input your Full-Time Rates for all categoriesInfant Group 1 (Birth to 12 months)Infant Group 2 (1-2 year olds)Toddler Group (2-3 year olds)Preschool Group (3-4 year olds)Kindergarten Group (5 year olds)School Age Group (6 years and older)VacanciesDo you have any vacancies currently? Please list them below including what age group.VacanciesCare Offered* Full time only Part time only Both full time and part time Drop-in Temporary/emergency basis Before and after school Rotating schedules 24-hour care Open on holidays Payment Subsidies Accepted - Check all that apply* DSHS Working Connections Childcare Subsidy Sliding scale Multi-child discount Military Opportunity Council Voucher (check from OC) Other subsidies Homeless Childcare Program Voucher List other subsidies hereFlexibility Opening time Closing time Occasional Saturday Occasional Sunday Occasional evening Occasional overnight Special Needs: Can you offer support in any of the following areas? Please check all that apply Behavior/Supervision Supports Communication Supports Diapering/Toilet Assistance Eating Assistance Health Monitoring Medication Monitoring Mobility Assistance Nursing Care Physical Therapy Respiratory Supports Sensory Integration Specialized Equipment Vision Supports Fees Registration Require payment in advance Supplies Transportation Enrichment activities Provider takes paid vacation Provider takes paid holidays Late child pickup Do you charge any additional fees?Can you or persons on your staff, converse in a language other than English? Yes No List additional languages hereHow Much Experience Do You and Your Staff have?How many years of experience do you and all of your staff have? Less than 1 year 1-3 Years 4-6 Years 7-10 Years 11-15 Years 16 or more Years
