REGISTRATION INFORMATION PAGE


Name & Address of your Child Care Facility

IMPORTANT! Please enter the unique name, actual physical address and zip code of the
child care facility for which you are registering. DO NOT use
headquarter/main office names or addresses. Registrations that appear to be duplicates
based on name/address/zip code combinations may be deleted.

* Required Fields

Name of Child Care Facility:  *
Street Address:  *
City:  *
State:  *
Zip Code:  *
Facility Phone Number: * e.g. 402-310-1111

 

Primary Contact Information

First Name:  *
Last Name:  *
Job Title:  *
(Mark all that apply)

Assistant

Other (please specify)



E-mail Address:  *

 

About Your Child Care Program

1. Which of the following describes your type of early childhood program? 
(Mark Only One) *
 

Child Care Center

Family Child Care Home

Preschool

   
1a. Is your child care program licensed to provide care to infants? *
 

Yes

No

   
2. What type of child care is offered at your program?
 

Full-day

Half-day

Both full- and half day

   
3. Enter the total number of children enrolled in your program. *
   
4.

Enter the number of children by age enrolled in your program.

0-23 months  

24-35 months

3-5 years

School age children (either in before and/or after school program or summer program) 

   
5. Does your program participate in the Child and Adult Care Food Program (CACFP)? *

Don't know

No

Yes   Go to 5a.

   
5a.

If participating in CACFP, then do you participate:

Through a sponsoring agency (e.g. Family Service, Provider’s Network, Midwest Child Care Association, Child Nutrition Services, Panhandle Family Daycare, etc.)

Through a state sponsorship (e.g. Nebraska Department of Education/Nutrition Services)

Other (please specify) -

Not applicable

   
6. What percentage of the total cost for all meals and snacks served by your program is reimbursed by CACFP?  (Mark Only One)
 

Not applicable

None

Less than 50%

50 to 59%

60 to 69%

70 to 79%

80 to 89%

90 to 99%

100%

   
7. What additional sources of money or in-kind support are currently used to cover the cost of meals and snacks that are served by your program? (Mark all that apply)
 

Money from Head Start program budget

Money from fundraising events

Money or food from a school or school district

Money or food from faith-based organizations

Money or food from local businesses

Food from food pantries or food banks

Food from parents

Other (please specify)

   
8. Which statement best describes who provides meals for your program? (Mark only one)
 

Cooks who are hired directly by our program

The food service program of a school, school district or school food authority

A food service company

Other (please specify)

I am a family child care home provider and I cook the meals for my child care.

 

   
9. Which meals and snacks are provided? (Mark at least one answer per line) *
 

Meal

Not provided

Usually provided by childcare setting

Usually brought from home by parents

a. Breakfast

b. Lunch

c. Dinner

d. Mid-morning snack

e. Mid-afternoon snack

f. Evening snack

g. Beverages (milk, juice, other drinks)
   
10. Does your child care program participate in Nebraska Step Up to Quality? *
 

Yes

No

Don't Know/Not Sure

11. Does your child care program accept child care subsidy? *
 

Yes

No

Don't Know/Not Sure

   
 
 

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