Online Profile Form

Provider Profile

| resume a previously saved form

Resume Later

In order to be able to resume this form later, please enter your email and choose a password.

Contact Information
As appears on license
First Name of Owner or Director
Last name of business owner or director
Location Address
Example: Harry & Oliver
Mailing Address
County you would like your report to cover?

*( )

( )

( )
Please provide your email address
License Information

School Information
School transportation

Add another elementary school

We can list three shift options in our database.  Complete the shift option section for each shift you offer (up to three).  After completing the first shift you provide, click the add another shift option button to add another one.

Shift Option

Start Time End Time
Rates & Capacity
Part Time Rate Rate Type Desired Capacity Licensed Capacity Desired SRS Capacity # Children Per Adult Number in Total Group
Under Age 1
1 up to 1.5
1.5 up to 2
Age 2
Age 3
Age 4
Age 5
6 & Over
Vacancy Information

TIP: Remember to keep your vacancies updated!  You can always call or visit the website to update your vacancies!

Full Time Vacancies Part Time Vacancies Vacancy Date
Under Age 1
1 up to 1.5
1.5 up to 2
Age 2
Age 3
Age 4
Age 5
Age 6 & Over

Add another shift (up to 3)





Training, Education, Experience & Skills

Family Child Care Owners

Census Questions

Please enter the characters you see in this picture:

This helps prevent automated form submissions. If you are not sure what the characters are, make your best guess. You will have another try in the next screen.

Need assistance with this form?

You may also choose to contact Candace Malone to update your information or print off a pdf version of this form (Family Child Care Profile) or (Child Care Center Profile) and mail in.


Change this in Theme Options
Change this in Theme Options