Opening Doors
Respite / Child Care Program Provider's Application

 
Contact Information
Name:
Address
City:
Zip:
County:
School District:
Phone:
Cell:
Fax:
E-mail:
Age:
Race:
(Optional-this helps us judge our diversity)
 
 
Education:
Please select highest level of education
   High School Graduate High School Incomplete
   College Graduate Currently enrolled in school
 
Please explain why you are interested in providing care for children with special needs:
  
 
Respite/Child Care Experience:
  
 
Experience working with children with special needs?
   Yes  No
  Please describe:
  
 
Special Training: Medical training (C.P.R, C.N.A, etc.)? Please describe:
  
  Other specific training or skills? (please include other spoken languages)
  
 
Special needs you are willing to consider:
   Apnea monitor Tube Feeding Autism
   Developmental Disabilities Down Syndrome Emotional Disorders
   Seizure Disorders Behavior Disabilities Cerebral Palsy
   Visual Impairment Asthma Colostomy
   Trach Diabetes Hearing Impairment
   ADHD Others:  Please list
 
Availability:
What hours are you available to do respite/child care?

Weekday Hours:

Weekend Hours:

Evening Hours:
 
Schedule:
What schedule best applies to you? (Select all that apply)
   Drop in for a few hours or ½ day in my home
   Temporary emergency short-term care
   Part-time child care
   Overnight care
   Pre-arranged hours
   Weekend respite
   5 day per week child care
   Flexible
   Weekday respite
 
Number of children you are able to care for:
  
 
Number of children you currently have in your care:
  
 
Age Group Interest: (Select all that apply)
   Infants/toddlers School Age
   Preschoolers Siblings welcome
 
Accommodations: 
Where you will provide care:
   Your home Child’s home Community based location
 
Should you provide care in your home, do you have any of the following?
   Pets Smoke-free environment
   Fenced yard Handicapped accessible (i.e. wheelchair ramp, etc.)
 
 Do you have a valid Minnesota Drivers License?
   Yes  No
 
 Do you have weight lift restrictions?
   Yes  No  
 
What distance are you willing to travel from your home?
  
 
Are you a licensed childcare provider?
   Yes  No
  If so, in which county?
  
 
Are you a respite care provider who contracts, is certified or registered with a county social service or other agency?
   Yes  No
  If so, which agency?
  
 
Has a MN Bureau of Criminal Apprehension search of your name been done during the past year?
   Yes  No
 
Was a criminal history record found?
   Yes  No
  Additional Comments:
  
 
Do you have a criminal history record?
   Yes  No
  If yes please explain:
  
 
Failure to disclose criminal history, or misrepresentation of criminal history is grounds for instant refusal into/or removal from the Opening Doors Program. Upon our discretion we may disclose this information to families that you intend to work for.
I wish my name and the information I have provided to be included in a database and provided to parents/guardians who request information on child/respite care for children with special needs. I understand that this database is for information purposes only and that all agreements, arrangements, and financial considerations are to be developed between the care provider and the parent/guardian.
 
   

Signature:

 ________________________________________
   

Date:

 _____/_____/__________
   
May we contact you in six months with a brief evaluation form to help determine how beneficial this project and training has been to you on a long term basis?
   Yes  No
 
We are very interested in continuing to help meet the needs of children, parents, and you the providers of specialized care. Are there any other topics of training that would be helpful to you to make you feel more confident and comfortable in including children with special needs in your service delivery system?
  
 
Would you like to be on our mailing list for newsletters, training information, etc.?
   Yes  No
 
Thank you for taking time to complete this form.