Canada Child Care Directory Printable Order Form

www.CanadaChildCareDirectory.com

Order Form- Premium Listing

Order Form

Please fill in the information below and send along with cheque made out to Eryn Wiedner and mail to us at PO Box 75225, White Rock, BC, Canada V4B 5L4. If you have any questions, please call us at (604) 614-7990.
Alternatively you may fill out the form online at www.CanadaChildCareDirectory.com/Online_Order_Form.htm

Please fill in as much information as possible in order for us to create a comprehensive web page for your facility. Please print clearly.

NAME OF CENTRE, SCHOOL OR DAYCARE (as it is to be published)

_______________________________________________________________________________________________

CIVIC ADDRESS / LOCATION ADDRESS (as it is to be published)

_______________________________________________________________________________________________

PHONE NUMBER (to be published) ( ) _______________________

CONTACT PERSON and TITLE / POSITION

OWNER/ MANAGER (not published)

___________________________________________________________________________

CONTACT PERSON PHONE NUMBER (not published) ( ) ___________________________

COMPLETE MAILING ADDRESS

_____________________________________________________________________________

FAX ( ) ______________________________

EMAIL ________________________________________________________________________

WOULD YOU LIKE THIS EMAIL INCLUDED ON THE WEB PAGE FOR PARENTS TO VIEW? YES / NO

WEBSITE ADDRESS (if applicable)

http://___________________________________________________________

PHILOSOPHY/ MISSION STATEMENT

_____________________________________________________________________________

DESCRIPTION/ PROGRAM INFORMATION/ PROGRAM HIGHLIGHTS

_____________________________________________________________________________

CENTER FEATURES (Please circle )

Indoor waiting area Snack / Meal Area Nap / Quiet Room

Reading Room/ Library Computer Terminals Offsite Outdoor Play Area

Onsite Outdoor Play Area Onsite Playground Air Conditioning

Close to schools (please indicate which schools) _____________________________________________________

OTHER CENTER FEATURES:

_____________________________________________________________________________________________

(Please feel free to include brochure / additional written information)

SCHOOL DISTRICT/ NEIGHBORHOODS SERVED

_____________________________________________________________________________________________

LICENSED? YES / NO

YEARS IN BUSINESS __________________________________

FACILITY TYPE (please circle)

Preschool / Group Child Care Center / Family Daycare or Home Child Care

Before & After School Care / Kindergarten Program

CURRICULUM TYPE (Please circle)

Academic / Developmental / Interactive / Special Education / Montessori

Other ___________________________________________________________________

CARE OFFERED (Please circle)

F/T P/T EVENINGS DROP- IN WEEKENDS

AGES (example “6 months – 5 years”) _________________________________________

________________________________________________________________________

CAPACITY: MAXIMUM ______________ CHILDREN

SUBSIDIZED SPACES AVAILABLE? YES / NO

HOURS OF OPERATION

________________________________________________________________________________________

INTEGRATED SPECIAL NEEDS? (Please circle) YES / NO

TOILET TRAINING REQUIRED?

_____________________________________________________________________________

IMMUNIZATION REQUIRED? YES / NO

TEACHER TO STUDENT RATIO’S (FOR ALL AGE CATEGORIES)

___________________________________________________________________________________________

LANGUAGES SPOKEN BY STAFF: __________________________________________________________

STAFF QUALIFICATIONS

________________________________________________________________________________________

STAFF HAVE CPR and / or FIRST AID TRAINING? YES / NO

FEE SCHEDULE (OPTIONAL)

_________________________________________________________________________________________

MEALS PROVIDED BY CENTRE, SCHOOL OR DAYCARE?

BREAKFAST – YES / NO LUNCH - YES / NO DINNER- YES / NO

SNACKS PROVIDED? HOW MANY PER DAY? EXAMPLES

__________________________________________________________________________________________

ACCOMODATION FOR SPECIAL DIETS? YES / NO

TRANSPORTATION AVAILABLE? IF YOU TRANSPORT TO AND FROM LOCAL SCHOOLS, PLEASE LIST SCHOOLS HERE AS WELL.

____________________________________________________________________________________________

CHURCH AFFILIATION/ RELIGIOUS ORIENTATION (If applicable)

_____________________________________________________________________________________________

PROFESSIONAL ASSOCIATION AFFILIATIONS

______________________________________________________________________________________________

Web page- (please circle the letter)

A. Please link to my website at http://_______________________________________________________________

B. I do have a website but I would prefer a FREE web page with all of the above information

C. I do not have a website and need a FREE web page created

If you chose B or C, please choose the following:

Background color of web page: (please circle)

White / Cream / Pale Pink / Pale Purple / Pale Blue / Pale Green / Pale Yellow

Pale Peach / Let us choose an appropriate color based on the graphic color for your page

Graphics
** Facilities may choose either one graphic, one photo, or one logo for the web page

** Crayons / Girl Dancing / Wizard / Baby Block / Fairies / Sports / Clowns

Planes, Trains & Automobiles / Sandcastle / Butterfly (pink or yellow) / Balloons

Jack-in-the-Box / Teddy Bear / Puzzle Pieces

** Graphic Request: __________________________________________________________________________

** Own Logo- please email to us in .jpg format

** One Photo from your center (we will not publish center photos with identifying information such as children’s faces for liability reasons)- please email to us in .jpg format or include with order form. Photos will NOT be returned.

PERSON WHO FILLED OUT THIS FORM ________________________________________________________

TITLE or POSITION __________________________________________________________________________

Thank you for taking the time to fill out this information. Once we receive this information we will have your web page up on the website within 72 hours and will send confirmation via phone or email.