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Provider Information Sheet

Child, Family and Community Services, Inc. - California Child Care Programs

SECTION I: Provider Contact Information

Provider’s Office/Home Phone:
Cell Phone:
Provider’s Email Address:

The following two (2) questions are for child care center and family child care homes.

Do you participate in the Quality Rating and Improvement System (QRIS)?:
Is your child care program accredited by an accrediting association?:
If your answer is “Yes,” please provide a copy of the accreditation certificate:

SECTION II: Days and Hours of Operation for Center and Licensed Day Care

MONDAY
From:
To:
TUESDAY
From:
To:
WEDNESDAY
From:
To:
THURSDAY
From:
To:
FRIDAY
From:
To:
SATURDAY
From:
To:
SUNDAY
From:
To:
24 HOURS
From:
To:

SECTION III - Non-Operational Days (holidays and/or vacation) for Center and Licensed Day Care

List Here:

SECTION IV: Non-Licensed Provider

Please list any employment in addition to CFCS childcare. Note: Other employment includes care with other similar subsidized agency andcareofchildrenofnon-subsidized parents.

Employer Name:
Work Phone:
Days/Hours of Work:
Date:
I understand that giving wrong or incomplete information can result in legal prosecution with penalties of fine and imprisonment or both. Under penalty ofperjury,Icertify that the above information is true and correct: