Child Care Provider Application for Early Head Start Child Care Partnership Contract.

Please fill out all the required fields before submitting the form.

Name(Required)
MM slash DD slash YYYY
Email(Required)
Address(Required)
Types of programs you are currently contracted with: (check all that apply and identify agency name)
Business Information(Required)
Do you have a High School diploma or GED?(Required)
Do you have a college degree?(Required)
Do you have a Child Development Permit? Or CDA Credential?(Required)
Number of ECE/Child Development Units(Required)
How did you hear about the Foothill Family EHS-CCP program?(Required)
How many children currently under your care between 0-4 are receiving subsidies?(Required)
Do you have any assistants? If yes, how many? And the type of permit they hold(Required)
Are you currently implementing a curriculum? If so, which one?(Required)
Are you currently using an assessment tool? DRDP?(Required)
Are you open to using technology to complete assessments?(Required)
Are you participating in the food program?(Required)
Do you have any Type A/B cited deficiencies?(Required)
Do you have liability insurance coverage?(Required)
Are you willing to increase coverage to 1,000,000?(Required)
Are you willing to reduce the capacity of your license while EHS-CCP children are enrolled in attendance?(Required)
I certify that all information provided above is accurate and complete. I understand that completing this application and providing my business information to FOOTHILL FAMILY does not guarantee that I will be selected to participate and does not constitute a contract. I further understand and agree that by providing the information hereby contained, I am consenting to visits by FOOTHILLFAMILY and its representative. Such visits are for the purpose of screening the environments (indoor and outdoor) I use to provide care to children.
Name(Required)
MM slash DD slash YYYY
I understand that as part of the selection process, I will need to provide Foothill Family with copies of my monthly financial statements for my business for the last 6 months and that Foothill Family will utilize that information to assess my fiscal viability as a CONTRACTOR.
Name
MM slash DD slash YYYY