Provider Intake Form

Provider Intake Form
The mission of the Child Care Helpline is to connect parents with quality child care providers in their area. Simply complete the form below and submit. This information will allow us to more accurately meet the needs of the parents and providers.

If you are already listed with us, simply update your information here.

Please remember all family in-home providers within Sioux Falls city limits must register with the city.

Thank you!
Name*

First NameLast Name
Business Name (if applies):
Type of Child Care*

Family Child CareGroup Family Child CareChild Care CenterPreschool ProgramBefore and After School Program
Address*

Street Address

Street Address Line 2

City

Zip Code
Phone Number*
Can we text?

YesNo
Email*
example@example.com
Email for Public Use
example@example.com
Website:
Social Media:
License Type (check all that apply):*

City Registered (required for all in-home providers within Sioux Falls city limits)State RegisteredPreschool Program
License/Registration Number: (If licensed Preschool program, put in zeroes)*
Education/Certificate/Degree Level for Staff:

High School EducationSome College, Child RelatedSome College, Other EmphasisAssociate Degree, Child RelatedAssociate Degree, Other EmphasisBachelor's Degree, Child RelatedBachelor's Degree, Other EmphasisGraduate Level
Days of Care Provided (check all that apply):*

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
Hours of Care Provided:*
I provide the following (check all that apply):*

Full TimePart TimeDrop InTemporaryBefore SchoolAfter School24 HourPreschool ProgramOpen HolidaysSchool Year OnlyFull YearSummer Only
Schedule Notes:
Rates

We know rates may be different for each age group; however, providing FT weekly rates for the groups below helps us educate parents on what to expect.
Infants
Toddlers
Preschool
School Age
Accepted Age Range: months* to years*.
Licensed Capacity:*
Desired Capacity:*
Infant Vacancies*
Toddler Vacancies*
Preschool Vacancies*
School Age Vacancies*
Are you on a bus route?*

YesNo
Which school(s)?
Do you provide transportation to/from school?*

YesNo
Which school(s)?
Are you within walking distance to a school (2 blocks)?*

YesNo
Which school(s)?
Policies(check all that apply):*

Written ContractWritten HandbookProvider Sick AllowanceProvider Vacation AllowanceChild Absence Allowance
Financial Assistance:

State Subsidy (Child Care Assistance)United WaySliding FeeHope CoalitionSibling Discount
Location type of business:

HouseTownhouseMobile HomeDuplexBusiness LocationChurch
Languages:

EnglishSpanishAmerican Sign Language (ASL)NepaliFrenchArabicSmaliSwahiliUkranian
Environment (check all that apply):

Preschool/Curriculum usedLearning CenterLarge Motor AreaFenced outside play areaNon-SmokingNo pets
Meal Information (check all that apply):

BreakfastMorning SnackLunchAfternoon SnackDinnerPart of a USDA Food ProgramAccommodates for special diet
Special Needs (check all that apply):*

Apnea MonitorsOther MonitorsBehavioral NeedsCognitive NeedsDispensing MedicationFeeding TubesHealth/MedicalSensory DisabilitySpecial DietNot applicable
Other information you would like parents to know or information you wish to explain:
We would appreciate any updates in your spot vacancies as they happen. By having this updated information, it allows us to give the most accurate information to parents regarding a providers availability for their child. Simply email childcare@helplinecenter.org with the number of vacancies for each age group or use this form located here.
Should be Empty: