Provider Update Form
Please use this form to inform Child Care Services Association if your facility has made any changes in its response to the current COVID-19 public health crisis. Please call us at 919-403-6950 or email us at referral@childcareservices.org if you have any questions or concerns.
Facility License Number (if applicable):
Facility/Camp Name *
Facility Type
Clear selection
City where facility/camp is located *
County
Clear selection
Name of person completing this form *
Who should we contact in the event your site is closed due to the current public health concerns surrounding COVID-19? *
What is the e-mail address for this contact person? *
What is the phone number for this contact person? *
What is the preferred way to reach this person if your facility is closed? *
Required
What are your intended plans for operation during the coming weeks? *
Required
If you are reopening, what date will you reopen?
MM
/
DD
/
YYYY
If you are closing, what date will you close?
MM
/
DD
/
YYYY
If you are closing, what date do you plan to reopen?
MM
/
DD
/
YYYY
If you are still accepting new enrollments, what ages are you currently accepting?
If you have children who are unable to attend care for an extended period of time (due to illness or quarantine), do you plan to hold the child's spot?
Clear selection
Is there anything else it would be helpful for us to know about your plans regarding closure or enrollment during this time?
Submit
Never submit passwords through Google Forms.
This form was created inside of Child Care Services Association. Report Abuse