Berry Family Child Care Network

BOX 30005  SAN BERNARDINO, CA 92413

(909) 886-2736

 Family Home Childcare Providers Network Community

Providers "FREE" Sign-Up

BERRY FAMILY CHILD CARE NETWORK - APPLICATION

TYPE or PRINT

DAYCARE NAME:______________________________PROVIDER NAME:_______________________________

ADDRESS:_________________________________________(will not be listed on website)

CITY:_____________________STATE:_______ZIP:___________ -_______

PHONE:_____-______-_______ FACILITY LICENSE#_________________

MAJOR CROSS STREETS:____________________NEAREST ELEM. SCHOOL:_________________________

TYPE OF CARE PROVIDED: check all that apply

__A (infants only up to 2yrs) ___B (infants & toddlers)___C (toddlers 2-5yrs)___D (school age)

___E (all ages)___F (evenings & weekends)___G ("special needs" children)___H (Provider of "sick" kids only)

DAYS AVAILABLE: check all that apply

MON__TUE__WED__THU__FRI__SAT__SUN__

HOURS AVAILABLE:

MON_____ -______TUE______-______WED_____-______THU_____-______

FRI______-______SAT______-______SUN_____-_______"23 HOUR" CARE YES( ) NO( )

MEALS PROVIDED: Breakfast_____Lunch_____Dinner______Snacks______

FEES: **Contact Provider**

FEES NEGOTIABLE : YES( ) NO( )

ACCEPT SUBSIDIZED Payments: YES ( ) NO ( )

( ) Yes I want to join Berry Family Child Care Network and participate in the opportunities that will be available to licensed Family Home Child Care Providers. I understand it is "FREE" to join at this time. Please List my Family Home Child Care on the Berry Family Child Care Network Web Site. I understand the Web Site Directory will be updated twice a year. I will be notified when the Web Site is to be updated, at which time I may continue to be listed by sending in the Update Request Form by the required due date.

RELEASE & WAIVER OF LIABILITY I, a Licensed Family Home Childcare Provider do hereby release, waive discharge, and covenant not to sue Berry Family Child Care Network or its originator Sharon Berry for liability, loss, injury, death, or property damage arising out of or related to my participation in Berry Family Child Care Network, whether caused by mistakes of content or typography. No gurantees, warranties, or representations of any kind will be made. Berry Family Child Care Network does not endorse any provider. All visitors will be urged to investigate and verify information through the Dept. of Social Services Community Care Licensing Office.

SIGNATURE__________________________DATE______________

1. Do you own or rent your childcare home? OWN( ) RENT( )

2. Would you like information on Health Insurance for yourself &/or employees? YES( ) NO( )

3. Do you need employees or want a temporary helper? YES( ) NO( )

4. Do you have a computer? YES( ) NO( )

5. Do you have access to the Internet? YES( ) NO( ) If Yes, Email_______________________

6. Do you have a FAX Machine? YES( ) NO( ) If Yes, FAX #_____________________

7. Are you interested in obtaining MONEY and/or EQUIPMENT for you Childcare business? YES( ) NO( )

8. Do you need help with Record-keeping & Business forms for your childcare business? YES ( ) NO( )

COPYRIGHT 1995-2006 BERRY FAMILY CHILD CARE NETWORK

SUBMIT: COPY OF FACILITY LICENSE