Child Care Resource & Referral, Northern Region                          801-626-7837  g 1-888-970-0101
Child Care Resource & Referral, Northern
helps Child Care Providers
do a better job

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Thank you for spending your precious time to help us collect this data!
All data collected will be used by the Utah Office of Child Care to educate the state on Child Care Issues.
If you choose, data collected will also be used to match parents seeking care to your program as well.
If you have already provided us with this information and would simply like to update your vacancies. You can fill out the smaller update form by following this link

General Information

First Name:  

Last Name:  

Business Name:

*Would you like to receive parent referrals? Yes   No
If at some point you find that you are full or don't want calls from parents, please let us know and we will no longer refer parents to you.

Location

Street Address:  

City:  

State:  

Zip Code:  
Mailing Address
(if different than the location of your program)

Address:

City:

State:

Zip Code:

Contact Information

Phone:  

Secondary Phone:

Fax:

E-mail address:  

Website:

Capacity

How many children are you licensed for:

What is your desired capacity at one time:  

How many total vacancies do you have:  
Accepted Age Range
(regardless of current openings)

What is the youngest age child you accept:  yrs mos

What is the oldest age child you accept:  yrsmos
Elementary Schools
Please list any schools, both public and private that you service. Please include if transportation is provided (either by you or by bus) or if children can walk to school.

  

Transportation is provided to and from school

The children walk to and from school
Schedule Information

  I provide care full time

I provide care on an occasional Saturday

 I provide care part time

I provide care on an occasional Sunday

  I provide care for children year round

I provide 24 hour care

  I provide care for children only during school year

I provide care during swing shift

  I provide care for children only during the summer

I provide care during grave shift

  I accept children on a drop in basis

I provide care occasionally in the evenings

  I accept school age children before school

I provide care occasionally overnight

  I accept school age children after school

I am open for all the major holidays

  I accept children after school on early out days

I am open on school holidays

  I accept children for temporary or emergency care

I only care for relative’s children

  I accept children whose schedule rotates between shifts

I can provide care for a child who is mildly sick

I have a special license that allows me to care for sick children
Days and Hours
Please enter the start and end time for the days in which you provide care

 

Start Time

End Time
Monday

 

 
Tuesday

 

 
Wednesday

 

 
Thursday

 

 
Friday

 

 
Saturday

 

 
Sunday

 

 

Rates
Please list your daytime prices for each age group. You do not have to fill in every box.
This information is used for statistical purposes only and to help us advocate for the needs of providers.
No rate information is ever identified with any individual provider.

 

Hourly
Part Time

Daily
Full Time

Weekly
Full Time

Monthly
Full Time

Under age 2

2 years

3 years

4- 5 years

Kindergarten
in school

Kindergarten
out of school

School-Age
in school

School-Age
out of school
Population Information
List your daytime full time and part time vacancies for each age group.

 

Full Time Vacancies

Part Time Vacancies

Number of Children Currently Enrolled in your Program

Under age 2

 

 

2 years

 

 

3 years

 

 

4-5 years

 

 

Kindergarten

 

 

School-Age

 

 

Special Needs
Please check all that apply

Special Need

Have Experience

Have Training

Willing to Get Training If Needed

ADHD/ADD

Allergies

Asthma

Autism

Blindness/Visual Impairment

Cerebral Palsy

Development Delays

Diabetes

Down Syndrome

Emotional/Behavioral

Epilepsy

 

Feeding Tube

Hearing Impairment

Learning Disability

Multiple Sclerosis

Muscular Dystrophy

Orthopedic Disabilities