Search: Pre-Kindergarten or HeadStart Provider Update Form 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. We do not want our name to be given out on referral lists at this time. We do not want our rates given out to parents. We are a newly licensed program. License Number: License Expiration Date: We are a license-exempt program. Program Information School Name & District: Contact Person: Site Address: Mailing Address (if different): Primary Phone Number: Secondary Phone Number: Phone Number for Early Childhood Screenings: FAX Number: Website: Email Address: Alternate Email Address: Number of lead teachers in program: Number of assistant teachers in program: Number of Parent Educators in program: Are meals provided? (Please Explain): Funding and Yearly Schedule Our program receives the following funding: HeadStart Funding Pre School for All Funding Our program runs Full Year Program Information Our program has a Kindergarten on-site. Our program has an elementary school on-site. Elementary Grades From: To: Staff have a valid CPR certification. Teachers have a valid certification in First Aid. Program has an on-site nurse. Rates: Our program does not charge a fee. If the program does charge a fee, please describe: Classroom Information: Number of preschool classrooms AM Number of preschool classrooms PM Number of preschool classrooms Full-Day Number of children in each classroom Number of current openings in program Date Registration Begins Preschool Screening Date(s) Ages Accepted: From: Years Months Days To: Years Months Days AM Session Start Time: End Time Please check the following days that the center is open: Monday Tuesday Wednesday Thursday Friday Saturday Sunday Addtional Information: PM Session Start Time: End Time Please check the following days that the center is open: Monday Tuesday Wednesday Thursday Friday Saturday Sunday Addtional Information: Full-Day Session Start Time: End Time Please check the following days that the center is open: Monday Tuesday Wednesday Thursday Friday Saturday Sunday Addtional Information: 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 TEACH recipient At least one of our staff is 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