Provider Info Page 1 Provider Info Page 2
Provider Information
Provider Name:   Phone:
Web Address:   Fax:
Address:   Email:
City, State Zip   Director:
County:   District:
Star Rating: (Numbers Only)   Sponsor:
Hours of Operation
Monday: to   Friday: to
Tuesday: to   Saturday: to
Wednesday: to   Sunday: to
Thursday: to      
Program Operates:      
Times & Types of Children Served Age Groups Offered
Schools Served: Before School, Ages 5-10: Yes     No
Ages Served: to Before School, Ages 11-13: Yes     No
Number of Children: Before School, Ages 14-18: Yes     No
Special Needs?: Yes    No After School, Ages 5-10: Yes     No
    After School, Ages 11-13: Yes     No
    After School, Ages 14-18: Yes     No
Services Provided for Each Age Group
Service Type Particpants Age 4 Participants Age 5-10 Participants Age 11-13 Participants Age 14-18
Sports/Recreation:
Arts/Culture:
Computer Training:
Character Development:
Conflict Resolution:
Homework/Tutoring:
Community Service Learning:
Leadership Development:
Life Skills:
First Grade Readiness Skills:      
Teen Clubs:    

Jobs/Career Choices:

     
College Prep:      
Others:
Transportation is Provided to Participants:
         Yes-                   No-
Services Offered to Participants Families:
Parent Resources:   Parent Involvement in Planning
and evaluation of Program:
Parent Seminars:   Parent Volunteer Support:
Parents Stay First Day:   No Services Offered to Families:
Parent-Teacher Conferences:   Other:
      Other Description:
Catagories of Fees Charged For Care:
Tuition Fee: Other Types of fees:
Registration Fees:
Insurance Fees :
Activity Fees: Yes No