Date:______________
Name:__________________________________________________________
Address:_________________________________________________________
Telephone:______________________________________________________
1. Do you have openings for my child(ren)?____________________
2. Will you be available to keep my child(ren) _____days a week?__________________
3. What is the cost for this care?_____________________________________________
4. What does this include?__________________________________________________
5. Are there any other cost?_________________________________________________
6. How many children do you currently provide for?_____________________________
7. What are the ages of the children who will be in my child's classroom or care in home?_________________________________
8. Is the building or home smoke free?_______________________
9. Do you have any pets?________________________________
If yes, what type of animals and where are they during the hours you are caring for children?______________________________________________________
10. What would be the routine and the types of activities for my child(ren)?_________________________
11. What are your discipline practices?_____________________________________
12. Are you licensed, registered, or exempt from licensure?_______________________
My impression of the provider:_____________________________________
References
Modified from
Division of Childcare and Development
Virginia Department of Social Services
Richmond,VA
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