Search: Family Child Care Provider Update Form This form is for licensed family childcare providers only. If you are license-exempt and would like to be on our database, please call 1-800-467-9200 x124 and request a "License Exempt Packet" to be mailed to your home. PLEASE NOTE: Use the tab key to move from field to field. If you hit ENTER, the form could be submitted before you are finished. I do not want our name to be given out on referral lists at this time. I do not want our rates given out to parents. I am a newly licensed program. License Number: License Expiration Date: Personal Information Name: Address: Primary Phone Number: Secondary Phone Number: FAX Number: Email Address: Alternate Email Address: Program Information Ages Served From: Years Months Weeks Ages Served To: Years Months Weeks Yearly Schedule: Full Year School Year Only Summer Only Addtional Staff: Full-time assistant Part-time assistant Schedule I open at: AM and close at PM Please check the following days that the center is open: Monday Tuesday Wednesday Thursday Friday Saturday Sunday I am willing to care for children: In the evening Overnight On the weekend (Saturday and/or Sunday) Full-time only Less than 5 hours per day Less than 5 days per week On a drop-in stauts Temporary/Emergency Status Before/After School On Holidays Whose parents work rotating shifts School-age during summer only Day Full-Time Enrollment Please enter# of children you are currently caring for during the day. Infants: One's: Twos's: Threes's & Four's: Five's: School Age: Total Day Full-Time Vacancies: Evening Full-Time Enrollment Infants: One's: Twos's: Threes's & Four's: Five's: School Age: Total Evening Full-Time Vacancies: School & Transportation Assigned School District: The school bus transports to the following schools: I transport to the following schools: I am within walking distance to the following schools: Yes, I provide regular transportation To/From Child's Home. Yes, I provide regular transportation on a case-by-case basis. Addtional Information: Rates: Yes, I charge the Illinois State Rate to all my families.          If this box is checked, it is not necessary to fill out the rates below. Infants Rate: $ per Month per Week per Day per Hour One's Rate: $ per Month per Week per Day per Hour Two's Rate: $ per Month per Week per Day per Hour Three's & Four's Rate: $ per Month per Week per Day per Hour Fives's Rate: $ per Month per Week per Day per Hour School age on school days Rate: $ per Month per Week per Day per Hour School age on non-school days Rate: $ per Month per Week per Day per Hour Additional Rate Information: Yes, I have multi-child discount Yes, I accept Child Care Assistance Payments Yes, I accept DCFS vouchers Yes, I am willing to negotiate rates with families Yes, we charge when a child is absent due to vacation or holiday Yes, we charge when a child is absent due to illness Environment: I do not have pets I have indoor pets I have outdoor pets My program is wheelchair accessible My yard is fenced in Total # of children with special needs enrolled: Total Special Needs Count Staff has expeience working with the following types of special needs: Emotional/Behavioral Physical Developmental Sign Language (Fluent) Asthma Visual/Hearing Sensory Special Health Needs Autism Gifted Premature Infants Down Syndrome Other    Please Specifiy Provider Education High School/GED 2 Year Degree 4 Year Degree MA/MS or Higher Early Childhood Education Degree Health Degree   Please specify Special Education Degree ISBE Pre-K Certification Elementary Education TEACHE recipient I am fluent in: English Spanish Sign Language Other    Please specify: Other Please add any additional information about your program here For questions regarding filling out this form or being listed on the database, please contact 1-800-467-9200. Back to top