First & Last Name:

Program/Facility Name:

Physical Address:

Nearest Cross Roads:

Mailing Address:

City:

Postal Zip Code:

  (5 digits)  ALASKA

Business Phone:

Home Phone:

 if different from business.

Email Address:

Verify Email:

Type of Facility/Provider:

Type of Facility/Provider Approved Provider Approved Relative Care Provider Coast Guard Certification Department of Defense Certification In-Home Provider Legally Exempt Provider Licensed Home Licensed Group Home Licensed Military Tribal Approval or Certification

 of Openings

Under 30 months:

0 1 2 3

Over 30 months:

0 1 2 3 4 5 6 7 8 9 10 11 12

Note:

Please note specific age accepted, if needed and hours   available for care, etc:

 Useful Information

Language Spoken:

To/From School Transportation? Yes, School transportation is available. No, School district bus transport only.

Do you participate in a USDA Food Program? Yes, Facility is enrolled in a USDA CACFP. No, Facility is not enrolled in a USDA CACFP.

Comments:

Please note other information about your child care program: