Christy Horn, Illinois AEYC Executive Director - 217-529-7732 ph / 217-529-7738 fax
PO Box 666, Vienna, IL 62995
Illinois AEYC Office - 217-529-7732

Provider Profile/Application
Please fill out the information below to apply for the SAM project. After you fill out this information, you will be taken to a confirmation page where you may review the entered information.

Contact Information
*Name of Program:
*Person Completing Form:     Title: 
*Program Administrator:     Title: 

Address of Program   Address of Program Site #2
(For multiple site programs)
*County:
*Street:
*City:
*Illinois Zip:
*Phone
*Email:
 
Street:
City:
Illinois Zip:
Phone:
Email:

Program Information
Program type (Check all that apply):
Licensed Child Care Center
Licensed Family Child Care Home

Do you operate a state funded PreK program Yes No
Do you operate a Head Start program Yes No
Are you a member of NAEYC Yes No    If yes, please provide your member number:

Program Sponsorship
Not-for-Profit Programs
Agency Sponsored
Church Sponsored
Government Sponsored (Head Start)
Public School Pre-School
Campus Child Care Program
Privately Sponsored
Other 		For-Profit Programs
Independent Owner
Corporate System
Other

Financial Information

Total Licensed Capacity:    Total Enrollment:
Number of Children enrolled by age groups:
Infants (birth through 12 months)
Toddlers (13 months to 35 months)
Pre-School (3 through 5 yrs. of age)
Kindergarten (public or private program)
School-age (6 years of age and older)

Licensed By DCFS? Yes No    If no, type of exemption:
What percentage of children you serve are funded by Illinois Department of Human Services? %

Has your program ever been accredited? Yes No
What professional organization accredited the program?
Have you applied to any other sources for financial assistance with accreditation costs? Yes No

If yes, please list other sources of financial assistance with accreditation costs:


Operations Information
How long has the program been in operation?  
What are your program's hours of operation?  
Days open per week:   Months per year:


Does your program change during the summer months? Yes No

If yes, please explain:

Number of administrators:
Number of teaching staff members:
Number of support staff: (such as business office, food service, housekeeping/maintenance)

Additional Comments:


Assistance
Type of assistance or participation you are requesting (you may choose more than one):
Access to online program improvement tool and accreditation readiness survey
Participate in quality improvement learning cohort
Initial on site observation visit to determine readiness for accreditation
On site mentoring for accreditation
Financial assistance with fees to apply for accreditation

Briefly describe your interest in quality improvement and/ or pursing accreditation:


What steps have you already taken to meet your program improvement/ accreditation goals:


Once your application is received, you will be contacted via email to review the available services and discuss your the steps needed for participation in the project. If approved, and funds are not immediately available, your program's names will be placed on a waiting list or you may request to receive the services for a fee. Failure to comply with the necessary documentation and paperwork may result in loss of future services from the SAM program.