Child care providers in Florida are asked to provide their local early learning coalition with updated information about their programs each year. The information collected on child care businesses helps with state and federal reporting, statewide child care analysis and captures statewide and local child care trends impacting communities. This information benefits your program, as well as families in their search for a child care provider. Thank you in advance for taking the time to provide your information. OPT OUT - I do not wish to complete this form, and I understand that my program will not be referred to families by the coalition. (School Readiness and VPK providers contracted with the coalition are required to complete this form.) *All fields on this page are REQUIRED, if applicable to your program. Name of Person Filling Out Form: Date Form Completed: Do you wish to have your program referred to families YES NO seeking child care listings from the coalition? Business Name: (as on License/Registration or name registered with DCF) Doing-Business-As Name: Owner Name: Director Name: City: County: Location Address: Zip Code: City: County: Mailing Address: Zip Code: Alternate Phone: Phone: Email: Fax: Family Child Care Large School-age Private Public Provider Type Center (check one): Home (FCCH) FCCH Only School School Do you want your house number and street name to appear on referral lists to families? Family Child Care Home Yes No Only: Legal Status Licensed Registered Exempt (check one): Faith Based: Yes No Exemption Type Religious Exempt Camp Non Public School Public School School Age (check one): Licensing DCF/Local Licensing ID: Expiration Date: Master School ID Federal Registration ID: (MSID): ID No: (Public and Private Schools only)
Child care providers in Florida are asked to provide their local early learning coalition with updated information about their programs each year. The information collected on child care businesses helps with state and federal reporting, statewide child care analysis and captures statewide and local child care trends impacting communities. This information benefits your program, as well as families in their search for a child care provider. Thank you in advance for taking the time to provide your information. OPT OUT - I do not wish to complete this form, and I understand that my program will not be referred to families by the coalition. (School Readiness and VPK providers contracted with the coalition are required to complete this form.) *All fields on this page are REQUIRED, if applicable to your program. Name of Person Filling Out Form: Date Form Completed: Do you wish to have your program referred to families seeking child care listings from the coalition? YES NO Business Name: (as on License/Registration or name registered with DCF) Doing-Business-As Name: Owner Name: Director Name: Location Address: City: County: Zip Code: Mailing Address: City: County: Zip Code: Phone: Alternate Phone: Email: Fax: Provider Type (check one): Center Family Child Care Home (FCCH) Large FCCH School-age Only Private School Public School Family Child Care Home Only: Do you want your house number and street name to appear on referral lists to families? Yes No Legal Status (check one): Licensed Registered Exempt Faith Based: Yes No Exemption Type (check one): Religious Exempt Camp Non Public School Public School School Age DCF/Local Licensing ID: Licensing Expiration Date: Registration ID: Master School ID (MSID): (Public and Private Schools only) Federal ID No:
Provider_Update_Form_2015-2016.docx