Search: School-Age Program 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 Faculty in program: This program runs: School Year Only Full Year Summer Only Maximum Capacity: Check here if no max cap (add faculty as needed:) Number of children enrolled in before-school session: Number of children enrolled in after-school session: Number of children enrolled in summer-school session: 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. Meals and/or snack provided. If checked, please explain: Transportation is provided. Parents are responsible for transportation. Addtional Information: After-School Session Start Time: PM End Time PM Please check the following days that the center is open: Monday Tuesday Wednesday Thursday Friday Saturday Sunday Addtional Information: Full-Day Session (if applicable) Start Time: End Time PM Please check the following days that the center is open: Monday Tuesday Wednesday Thursday Friday Saturday Sunday Addtional Information: Rates: Yes, We charge the Illinois State Rate to all my families.          If this box is checked, it is not necessary to fill out the rates below. Before School Only: $ per week After School Only: $ per week Both Before & After School: $ per week Full Day (School not in session): $ per week Addtional Rate 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