Child Service Provider Application Please complete this form if you are a Service Provider interested in partnering with PA4Kids. Contact First Name Contact Last Name Name of Business Owner/Director Website URL Address Address 2 City State Zip Email Phone Type of Service You Provide Childcare Education Boxing Swimming Karate Dance Music Other If other, please list below. Services Pre-K Drop In Evening Summer Camp Transport To Transport From In-Home Lessons In-Studio Lessons Gym Lessons Other If other, please list below. Age Group Infant - 0-12 Months Toddler - 13 Months- 2 Years Pre-School - Age 3-4 School Age - Age 5 Over 6 Years Days of Operation Monday Tuesday Thursday Friday Saturday Sunday Hours of Operation Max # of Children Number of Employees Number of Teachers/Instructors Years in Business State License Date Last State Inspection Date Accredited By ACTS APPLE NACCP NAEYC NAFCC NECPA None State Quality Rating None 1 Star 2 Star 3 Star 4 Star 5 Star Gold Star Other BBB Rated Yes No State Violations None 0-3 3-5 Over 6 Parent Interactive Software Yes No In-Class Cameras Yes No Secure Door Controllers Yes No Check In/Out Method Manual Automated Playground Indoor Outdoor Both None Accept Child Care Subsidy Yes No Scholarships Awarded Accepted Not Accepted Curriculum SUBMIT SERVICE REQUEST
