Vacancy and Rate Quarterly Update Form

Form Completed By: ^*		Date:
Contact Person:
First Name: ^*		Last Name: ^*
(Director/Provider if different than person completing form)
Business Name: ^*

Street Address: ^*
City: ^*		State: ^*	Zip Code: ^*

Phone: ^*		Fax:		Email Address:
(Enter with dashes XXX-XXX-XXXX)

No Vacancies (check here if you do not have any current vacancies in your program and proceed to completing rate information)

Please complete vacancy & rate information in the chart below

Full-time: Includes all care provided a minimum of (30 hours per week) 5 days/6 or more hours a day.

Part-time: Includes all care provided less than 30 hours per week or fewer than 5 days and less than 6 hours per day.

Special Needs: Includes children 13 and older with chronic and on-going special needs with a mental age under 12.

InterCounty Childcare Connection