LifeWorks Child Care Center (CCC) Provider Form

LifeWorks Child Care Center (CCC) Provider Form
The fields marked with an * below are required fields and must be completed before you can submit this form. If you have any questions while completing this form you can contact us at Central.DB@Ceridian.com or call our Provider Line at 800 290-4311, extension 5862. Leave your name and phone number and someone will return your call.

* New Provider Information Updated Provider Information

Provider Name *
Phone *
Main Contact *
Address *

City *
State*
Zip *
Email Address*
Licensure *	Licensed Exempt
Director:
Capacity:
Hours of operation:	From: : AM PM To: : AM PM
Ages Served:	From: To:

Please check off any of the following that apply:

Services Before & After School Care Drop-In / Backup Care Evening Care Experienced With Special Needs Children Full-Time Care Head Start Program Kindergarten Overnight Care Part-Time Care Preschool / Nursery School School-Age Summer Program Sick Child Care Weekend Care Facilities Fenced Area Local Parks Utilized No Pets Non-Smoking environment Outdoor Play Area Outdoor Play Equipment Pets - Indoor Pets - Outdoor Pets - Small Caged Pool Staff Training Additional Languages Child Development / Education CPR Degree First Aid Montessori Certified Spanish Speaking Special Needs Training	Fees Corporate Discounts Deposit / Registration Fee Drop-In Care Fee Extended Hours For Additional Fee Multiple Child Discount Part-Time At Full-Time Rate Part-Time Care Fee School Age Fee Sliding Fee Scale Subsidized Care Transportation For An Additional Fee Meals provided Breakfast Child Care Food Program Formula Lunch Parents Provide Meals Snacks Activities Developmentally Suitable Activities Educational TV Field Trips Free Play Learning Through Play Montessori Based Program Outside Play Theme-Based Activities Traditional Day Camp Activities Holiday Schedule Open School Year Only Open Summer Only Open Year Round

Additional Information/Comments: