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CCA-0100A FORFF (3-21) Page 1 of 2 ARIZONA DEPARTMENT OF ECONOMIC SECURITY Division of Child Care Administration PROVIDER’S CHILD CARE OPERATIONAL INFORMATION See the reverse for completion instructions - Routing: Original – Contract File; Canary – Provider 1. Facility’s Name: 2. Facility’s Phone Number (Include area code): : Facility’s Fax Number (Include area code) 3. Facility’s Address: City: State: ZIP Code: 4. Mailing Address (If different from Facility Address): City: State: ZIP Code: 5. County: 6. Owner’s Full Name: 7. Department of Health Services (DHS) License DHS CDC or SGH No.: DHS Licence End Date: 8. Tax Reporting Classification (Check one): For Profit Non-Profit 9. Type of business: Military Base Public School Corporation Indian Tribe Minority Business Sole Proprietorship If an incorporated site, a school district site or church owned, complete Item 10 through 14 10. Corporation Name/School District Name/Church Name 11. Phone Number (Include area code): 12. Locational Address: City: State: ZIP Code: 13. Contact Person & Title for CCA: 14. Facility/Provider Email Address: 15. Age range of Children to be served by your facility (Check all that apply): Infant (Birth to 12 months) Toddler (1-2 years) Preschool (3,4, & 5 years) School-Age (6 through 12 years) 16. Weekly Hours Open (Monday - Friday): Opening Time: AM PM Closing Time: AM PM 17. Weekend Hours Open (Saturday - Sunday): Opening Time: AM PM C losing Time : AM PM Do you provide Child Care 24 hours 7 days a week? Yes No 18. Check the days your facility will be closed during the year New Year’s Day Martin Luther King Day President’s Day Memorial Day Independence Day Labor Day Columbus Day Veterans’ Day Thanksgiving Day Christmas Day 19. Check all that apply: Transportation Provided Registration Fees Applied Charge Parent for Days Child Does Not Attend Facility Meals Provided I am Participant of the Child and Adult Care Food Program 20. Are you a *Sectarian Organization or Sectarian Child Care Provider: Yes No * “Sectarian organization or sectarian child care provider means religious organizations or providers generally, not merely those of a specific religious character or that are affiliated with a church or synagogue. The terms embrace any organization or provider that engages in religious conduct or activity or that seeks to maintain a religious identity in some or all of its functions. There is no requirement that a sectarian organization or provider be managed by clergy or have any particular degree of religious management, control, or content.” (Child Care and Development Block Grant 45 CFR Part 98.2 ii) 21.Signature of Owner or Person Authorized to Sign : 22.Title of Person who Signed Line 21: See page 2 for EOE/ADA disclosures CCA-0100A FORFF (3-21) Page 2 of 2 PROVIDER’S CHILD CARE OPERATIONAL INFORMATION Completion Instructions for CCA-0100A A. Purpose: Registration for the provision of child care services is designed to provide demographic information and service delivery capability on the part of the provider and ensure payment for eligible child care services. The information will become a permanent part of the Child Care Provider Registration Agreement (Agreement) and Contract File if a registration agreement is awarded. It will also be used to input information in the computer. Therefore, accuracy in preparing this document is essential. ALL SECTIONS MUST BE COMPLETED. IF A SECTION DOES NOT APPLY, MARK “N/A,” (NOT APPLICABLE). B. Completion: Items not listed are self-explanatory. 1. FACILITY’S NAME – Enter the full business name of the facility. 6. OWNER’S FULL NAME – Enter the name of the owner(s) if sole proprietorship or partnership. If incorporated, enter the name of the corporation. If governed by a school district enter the school district’s name. If owned and operated by a church enter the church’s name. 7. DEPARTMENT OF HEALTH SERVICES (DHS) LICENSURE – Enter your DHS assigned CDC number (issued to a Child Care Center) or SGH number (issued to a Group Home), and license end date if presently licensed by DHS. 10.CORPORATION NAME OR SCHOOL DISTRICT NAME OR CHURCH NAME – If incorporated, enter the name of the corporation. If governed by a school district enter the school district’s name. If owned and operated by a church, enter the church’s name. 11.AREA CODE & PHONE NO. – Enter the phone number and fax number of the corporation, school district or church. 13.CONTACT PERSON’S FULL NAME AND TITLE FOR CHILD CARE ADMINISTRATION – Enter the name of the person the Contracts Unit can contact regarding contractual issues. 15.AGE RANGE OF CHILDREN TO BE SERVED BY YOUR FACILITY – Mark the age group of children that services will be provided for. Note: only mark the age group boxes DHS has licensed your facility to provide child care services for. 20.ARE YOU A *SECTARIAN ORGANIZATION OR SECTARIAN CHILD CARE PROVIDER – If the facility is owned and operated by a church organization, mark the “Yes” box, otherwise mark the “No” box. C.Routing. Original is placed in the contract file. The Canary copy is attached to the Agreement and forwarded to the provider for retention. D.Retention.This record shall be retained for a period of five (5) years after termination of the Agreement. Equal Opportunity Employer / Program • Auxiliary aids and services are available upon request to individuals with disabilities • To request this document in alternative format or for further information about this policy, contact 602- 542-4248; TTY/TDD Services: 7-1-1 • Disponible en español en línea o en la oficina local.