Family Child Care Provider Pre-Qualification Form

First Name:*

Last Name:*

Age:*

Address*

Street Address Address Line 2 City State ZIP Code

Work Phone:

Home Phone:*

Email*

Do you have at least two years of experience working with children (family or otherwise)?

Do you live in the place where you will provide care?

Do you agree to care for children regardless of race, color, gender, religion, national origin or handicapping condition?

How many children live in your home?

What are their ages?

Do you have access to space and opportunities for children to join in safe and active outdoor play?

Do you have enough room to set aside space for children to safely eat, play and nap?

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