Services provided in all 15
Upper Peninsula counties at no charge

Provider Referral Information

First Name:

Last Name:

Email (REQUIRED):

County:

Month/Year:

Business Name:

Contact Person:

Mailing Address:
City:		State:		Zip:		Phone:

License/Registration#:

Expiration Date:

Total Capacity:

Currently Caring for Children?

Youngest Age You Will Accept:

Oldest Age You Will Accept:

Nearest Elementary School:

Do You Transport Children to/from School?

On Bus Route?

Within Walking Distance?

Would you like to be listed/referred on the 4C-up.com website?

Social Security # / EIN:

Schedule of Operations				Shift Vacancies
Day of the Week	Begin Time	End Time	24 Hour Care	Day Vacancies	Number under 18 months	Evening vacancies	Number under 18 months	Overnight vacancies	Number under 18 months
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Fees
	Infants 0-18 months	Toddlers 19-30 months	Toddlers 31-36 months	Preschool 3-5 years	School age 6-12 years	Or do you charge a weekly rate?
Full Time Cost per Hour						Full Time Weekly Amount
Part Time Cost per Hour						Part Time Weekly Amount

Do you charge en enrollment fee?		If yes, how much is the fee?
Do you charge a late pick-up fee?		If yes, how much is the fee?
Do you offer sibling discounts?		If yes, how is it broken down?
Do you participate in CDC FIA positive billing?

	High School Diploma?	Some College - Child Related?	Some College - Other emphasis	Associates Degree - Child Related	Associates Degree - Other emphasis	Bachelors Degree - Child Related	Bachelors Degree - Other emphasis	Do you have a CDA credential?
Director
Assistant Director
Staff 1
Staff 2
Staff 3
Staff 4
Staff 5
Staff 6
Staff 7
Staff 8
Staff 9
Staff 10

How many staff have completed the following training?

MFCC Basic Futures:	MCC Advanced Futures:	MCC Administrative Futures:
MCC Infant/Toddler Training:	MCC Special Needs Training:	CPR (within 2 years):
First Aid (within 2 years):	Any Medical Training/Degree:

Would you like information on the following? (select yes or no)

Obtaining a CDA:		Early Childhood College Courses:
TEACH Scholarships to help pay for further education:		Are you partnered with Head Start:
Is your program NAEYC accredited?:

Do You Provide:		Meals:
Drop in Care?		Are you enrolled in a food program?
Temp/Emergency?		Do you offer ... breakfast?
Sick Child Care?		Morning Snack?
24 Hour Care?		Lunch?
Extended Hours?		Afternoon Snack?
Weekend Care?		Dinner?
Flexible Hours?		Evening Snack?
Waiting List?		Special Diet?
Do you have training in the following areas?
Autism		Downs Syndrome
Asthma		Vision Impaired
Breathing Treatment		Hearing Impaired
Apnea Monitor		Emotionally Impaired
Seizure Disorder		Wheel Chair Bound
Feeding Tube		Behavioral Challenges
ADD/ADHD		Drug exposed infant

Child Care Environment
Is your home Smoke Free 24 hours a day?		Do you have air conditioning?
Do you have a swimming pool or live by a lake?		Do you have pets?
Do you have a fenced in yard/play area?		If so, what?

Please enter the verification code shown below prior to submitting this form.

Verification code:

TWDPC

Marquette / Alger Counties

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Provider Referral Information

Schedule of Operations

Shift Vacancies

Fees

How many staff have completed the following training?

Would you like information on the following? (select yes or no)

Do You Provide:

Meals:

Do you have training in the following areas?

Child Care Environment