Form Center

2. Home-Based Childcare Network Interest Form

   Thank you for your interest in the Home-Based Childcare Network. Please complete the below interest form and a HCN Specialist will be in contact.

3. 
5. First Name*
6. Last Name*
8. Address1*
9. Address2
11. City*
12. State*
13. Zip*
15. Email Address*
16. Phone Number*
18. Personal Considerations
20. Do you have any health-related concerns that would prevent you from working with children?*

    1. Yes
    2. No
    3. Not Sure
21. Do you possess a high school diploma or equivalent?*

    1. Yes
    2. No
    3. Not Sure
22. Can you effectively manage your own business?*

    1. Yes
    2. No
    3. Not Sure
23. Are you willing to participate in ongoing trainings?*

    1. Yes
    2. No
    3. Not Sure
25. Are you aware of the potential personal and financial cost associated with starting/maintaining a family day care home?*

    1. Yes
    2. No
    3. Not Sure
26. Do you have a criminal background?*

    1. Yes
    2. No
    3. Not Sure
27. Does anyone in your household have criminal background?*

    1. Yes
    2. No
    3. Not Sure
29. Family Considerations
31. Does your family support the operation of a child care program in your home?*

    1. Yes
    2. No
    3. Not Sure
32. Will your own children accept the other children?*

    1. Yes
    2. No
    3. Not Sure
33. Will your own children be able to share you and your time with other children?*

    1. Yes
    2. No
    3. Not Sure
34. Will your family support other children being in the home when they come home from school or work?*

    1. Yes
    2. No
    3. Not Sure
36. Home Considerations
38. Do you have permission from your landlord to operate a business if you do not own your home?*

    1. Yes
    2. No
    3. Not Sure
39. Does your home have space for children's activities or children to nap?*

    1. Yes
    2. No
    3. Not Sure
40. Do you have safe outdoor play area in your yard or within walking distance?*

    1. Yes
    2. No
    3. Not Sure
41. Does your home have an area for diaper changing?*

    1. Yes
    2. No
    3. Not Sure
43. Neighborhood Considerations
45. Do you have two (2) on-site parking space for parents to drop-off/pick-up children?*

    1. Yes
    2. No
    3. Not Sure
46. Have you talked to your neighbors about operating a child care program in your home?*

    1. Yes
    2. No
    3. Not Sure
47. Will the noise of children playing outside affect your neighbors?*

    1. Yes
    2. No
    3. Not Sure
48. Is there an outdoor space available for children's use?*

    1. Yes
    2. No
    3. Not Sure
Leave This Blank:


50. 1. Receive an email copy of this form.
51. Email address

    This field is not part of the form submission.

52. Submit Submit and Print

* indicates a required field