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Center Whole Record Update & Intake Form
Name of Center (*)
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Director First Name (*)
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Director Last Name (*)
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Center Address (*)
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City (*)
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State (*)
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Zip Code (*)
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Phone (*)
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Fax Number
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Website
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Email (*)
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Mailing Address
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General Information

Do you want your program to be on our referral list? (*)
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How many children are you willing to care for in your program at one time? (*)
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What is the youngest age of children you will accept? (*)
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What is the oldest age of children you will accept? (*)
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How many caregivers work in your program (not including volunteers, cooks, drivers, housekeepers)? (*)
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I provide transportation to and from school (*)
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The children walk to and from school (*)
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Elementary Schools Served (please list any schools, both public and private that you service):
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Days Care Provided

Do you accept children full time, part time, or both full time and part time? (*)


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Do you provide care year round, during the school year only, or during the summer only? (*)


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Do you offer care 24 hours a day? (*)
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Do you offer after school care for school age children? (*)
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Do you offer care after school on days chidren are released early for school age children? (*)
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Do you offer before school care? (*)
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Do you provide drop in care (accept child for a short period of time on short notice)? (*)
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Do you care on graveyard shift (12am - 7am)? (*)
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Do you provide care for a child that is mildly sick? (*)
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Do you provide care on occasion in the evening or overnight? (*)
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Do you offer care on an occasional Saturday? (*)
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Do you provide care on an occasional Sunday? (*)
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Are you open on school holidays that are not State/National holidays? (*)
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Are you open on State/National Holidays? (*)
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Do you only care for relatives? (*)
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Do you provide care for families that work rotating shifts? (*)
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Are you willing to participate in our Kids in Care program? (*)
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Do you provide care for families that work swing shifts (4pm - 12 am)? (*)
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Do you provide care in a temporary situation or in an emergency? (*)
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Days and Hours

Monday Start Time
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Monday End Time
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Tuesday Start Time
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Tuesday End Time
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Wednesday Start Time
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Wednesday End Time
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Thursday Start Time
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Thursday End Time
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Friday Start Time
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Friday End Time
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Saturday Start Time
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Saturday End Time
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Sunday Start Time
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Sunday End Time
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Capacity

0-11 Months

Number of Rooms
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Licensed Capacity
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Full Time Vacancies
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12-23 months

Number of Rooms
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Licensed Capacity
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Full Time Vacancies
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2 years

Number of Rooms
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Licensed Capacity
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Full Time Vacancies
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3 years

Number of Rooms
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Licensed Capacity
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Full Time Vacancies
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4 to 5 years

Number of Rooms
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Licensed Capacity
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Full Time Vacancies
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Kindergarten

Number of Rooms
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Licensed Capacity
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Full Time Vacancies
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School-Age

Number of Rooms
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Licensed Capacity
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Full Time Vacancies
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Total Number of Full Time Vacancies

Total number of vacancies for children 23 months and younger (*)
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Total number of vacancies for children 2 years old and older (*)
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Facility Information

Number of diapering stations? (*)
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Number of restrooms? (*)
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Number of playgrounds? (*)
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Enrollment and Rates

0-11 Months

Current Enrollment
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Monthly Rate
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Weekly Rate
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Daily Rate
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Hourly Rate
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12-23 months

Current Enrollment
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Monthly Rate
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Weekly Rate
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Daily Rate
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Hourly Rate
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2 years

Current Enrollment
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Monthly Rate
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Weekly Rate
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Daily Rate
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Hourly Rate
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3 years

Current Enrollment
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Monthly Rate
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Weekly Rate
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Daily Rate
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Hourly Rate
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4 years

Current Enrollment
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Monthly Rate
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Weekly Rate
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Daily Rate
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Hourly Rate
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5 years (Pre-K)

Current Enrollment
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Monthly Rate
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Weekly Rate
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Daily Rate
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Hourly Rate
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Kindergarten - in school

Current Enrollment
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Monthly Rate
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Weekly Rate
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Daily Rate
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Hourly Rate
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Kindergarten - out of school

Monthly Rate
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Weekly Rate
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Daily Rate
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Hourly Rate
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School Age - in school

Current Enrollment
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Monthly Rate
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Weekly Rate
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Daily Rate
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Hourly Rate
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School Age - Out of School

Monthly Rate
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Weekly Rate
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Daily Rate
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Hourly Rate
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Special Needs

Will you be willing to care for a child with special needs? If so, please mark the type of special needs:





















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If you marked "other," please list:
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Languages

Please mark all the languages spoken in your program:













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If you marked "other," please list:
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Environment

I offer an educational preschool program for 3-5 year olds. (*)
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I never allow smoking on the premises including after hours. (*)
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There is Public Transportation (UTA) near my facility. (*)
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I have pets that interact with the children in my program. (*)
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National Accreditation

Please mark the organization by which your program is nationally accredited:




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Other Information

Please use this space to provide other information about your program which you would like us to know or share with parents.
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If you need to update other information or have questions about this form, please contact our office at 801-355-4847 or 866-438-4847 - Monday through Thursday 7:30 AM - 6:00 PM(MST)

Funding for Children’s Service Society is provided by the following organizations and agencies

Ally Bank
American Express
Castle Foundation
The Church of Jesus Christ of Latter-day Saints Foundation
Daniels Fund
Department of Workforce Services – Office of Child Care
eBay Give
Edwards Lifesciences Fund
Energy Solutions
Frances W. Burton Foundation
George & Dolores Doré Eccles Foundation
Henry W. and Leslie M. Eskuche Foundation
Herbert I. and Elsa B. Michael Foundation
In-N-Out Burger Foundation

Intermountain Healthcare Community Partner Fund
John & Dora Lang Foundation
Kennecott Utah Copper Charitable Foundation
Larry H. Miller Charities
Lawrence T. Dee & Janet T. Dee Foundation
Marriner S. Eccles Foundation
R. Harold Burton Foundation
Ruth Eleanor & John Ernest Bamberger Memorial Foundation
Salt Lake County Substance Abuse Prevention Services
Sorenson Legacy Foundation
Sterling & Shelli Gardner Foundation
United Way of Salt Lake
UPS Foundation
Utah Division of Child & Family Services
Utah Health Department, Office of Home Visiting
Utah Masonic Foundation