Join our Child Care Referral Network

Join the CGCC Child Care Partners network of providers by filling in the form below. Once enrolled, we will refer parents to your services. Contact us if you have any questions. * Required

Contact Info

First Name *

Last Name *

Date of Birth

Last 5 Digits of SSN# *

Business Name *

Business Address *

City *

Zip *

Different mailing address

Address

City

Zip

Phone 1 *

Phone 2

Fax

Email *

Preferred Communications

Email

Fax

Spanish

About Your Business

Business Start Date

When did you first start providing child care serviced?

License Type

Not sure? Read Types of Child Care in Oregon.

Exempt Family Child Care

Exempt Preschool or Center

Registered Family Child Care

Certified Family Child Care

Certified Child Care Center

Registration #

Expiration Date

Have children of your own?

No

Yes

Your Children's Ages

Exempt Family Child Care

A child care provider is not required to be licensed if they...

Only care for children on an occasional basis
Care for 3 or fewer children or children from only one family at a time, not including your own children
Are a primarily educational program for children three years old and older, but not attending kindergarten, for four or fewer hours a day
Provide care in the child’s own home
Are related to the child by blood, marriage or adoption

Exempt Preschool or Center

Operate for four hours a day or less
Are an educational program
Serve children from 36 months to eligible to attend public school

Registered Family Child Care

Provide care for children other than in their own home
Provide care on more than an occasional basis
Provide care to more than 3 children or children from more than one family
May care for up to 10 children, including their own. Of the 10, only 6 children may be kindergarten eligible or younger, and of the 6 children only 2 may be under the age of two.

Certified Family Child Care

Provide care for no more than 16 children in their own home
Ages of the children cared for is dependent on the age of the children and the number of staff working in the home

Certified Child Care Center

Provide care in a facility other than their own home.
The number and ages of children is dependent on the number of staff working in the center and the square footage of the rooms children are in

Openings and Capacity

Children's Age Range Served

From

To

Number of Current Openings

6 weeks - 1 year old

1 - 2 years old

2 - 6 years old

Kindergarten and up

Desired Capacity (exclude your own children)

Hours

Hours of Operation

From

To

Extended Hours (Select all you accept on a regular basis or are willing to consider)

Rates

	Full-time	Part-time	Part-time	Full-time	Full-time	Part-time
Infants 6 weeks to 1 yr
Toddler, 1 yr to 2 yr
Preschool, 2 yr to 5 yr
Kindergarten and up

Explain

Facilities and Services

Ethnicity

Select the ethnicity you most relate to or most requested by current staff.

Primary Language

Other Languages

Transportation

Walking distance to school

Close to school bus

Transportation provided

To which schools?

List all schools to which you do or are willing to transport children.

Philosophy

Montessori

Waldorf

Religious curriculum

Education, Training and Skills

Training

Dollars and Sense

Social & Emotional Module 1

Social & Emotional Module 2

Social & Emotional Module 3

Social & Emotional Module 4

First Connections Module 1

First Connections Module 2

First Connections Module 3

First Connections Module 4

Experience

Trained as child care provider mentor

Center care experience

Previous family child care experience

K-elementary classroom teacher

Experience with medical assistance

Other

Explain

Accreditations and Affiliations

Accreditation

NAFCC

NAEYC/NAECP

NSACA

CDA

Terms and Conditions

I understand that Child Care Partners (CCP), Columbia Gorge Community College, only makes referrals, not recommendations to families.

I agree to assist CCP in maintaining up to date information on child care availability by reporting changes in my Child Care home/business when they occur.

I give CCP permission to release the information on this form to parents seeking child care services.

In addition, CCP occasionally releases the names and addresses of listed providers to carefully screened child care related agencies and organizations. Unless otherwise indicated, I give CCP permission to release my name and address to such agencies and organizations.

I agree to the Terms and Conditions.

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