Application for M.O.R.E.
Service
Name of
Address of
____________________________________________________________________________________
Daycare Center’ FAX
Number:____________________________________________________________
Name of Daycare Center
Director:__________________________________________________________
Director’s Telephone
Number:_____________________________________________________________
Day Care License Number:_______________________________________________________________
Licensing Agency:_____________________________________________________________________
Number of Years
Established:_____________________________________________________________
Have you ever received
M.O.R.E. service?
______ No
______
Yes If yes what year(s):_________________________________________________
Type of Center (Check
One)
______ Non–profit _______Church _______ Profit _______Private
Funding Source:_______________________________________________________________________
Percent of Funding from
Local Government:_____________________
State Government:_____________________
Federal Government:___________________
Percent of children from
economically disadvantaged households:
3 years old__________________________
4 years old__________________________
5 years old__________________________
Enrollment Capacity Current Enrollment____________________
Current Enrollment by
Age:
3’s_____________ Number
of classes_____________
4’s_____________ Number
of classes_____________
5’s_____________ Number
of classes_____________
Meals and snack times:__________________________________________________________________
Hours of Operation:____________________________________________________________________
Can you provide an area
where a storytime can be conducted with a minimum of outside distractions?_______
____________________________________________________________________________________
A60.1 Attachment I
Page
2
Please fill out the
following times when your daycare would be available for storytime:
Our center would be
available for storytime:
Mornings:
_____ Monday between __________ and __________ except on __________ (e.g. 1st Mon. of the month)
_____ Tuesday between __________ and __________ except on __________
_____ Wednesday between_________ and __________
except on __________
_____ Thursday between __________ and __________ except on __________
_____ Friday between __________ and __________ except on __________
Afternoons:
_____ Monday between __________ and __________ except on __________
_____ Tuesday between __________ and __________ except on __________
_____ Wednesday between_________ and __________
except on __________
_____ Thursday between __________ and __________ except on __________
_____ Friday between __________ and __________ except on __________
Our center will be
closed on the following dates:
January ___________________________
February ___________________________
March ___________________________
April ___________________________
May ___________________________
June ___________________________
July ___________________________
August ___________________________
September ___________________________
October ___________________________
November ___________________________
December ___________________________
A60.1
Attachment
1
Page
3
Describe the special
needs, if any, of the children in your center:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Current employees and position: (use an
additional page if necessary)
_____________________________________ __________________________________________
_____________________________________ __________________________________________
_____________________________________ __________________________________________
_____________________________________ __________________________________________
_____________________________________ __________________________________________
_____________________________________ __________________________________________
_____________________________________ __________________________________________
_____________________________________ __________________________________________
_____________________________________ __________________________________________
_____________________________________ __________________________________________
_____________________________________ __________________________________________
Attach a copy of your
IRS 501(c)(3) if applicable.
Director’s
Signature:____________________________________________________________________
Date:________________________________________________________________________________
Mail to: Children’s Coordinator
Chattanooga–Hamilton
County Bicentennial Library
1001 Broad Street
Chattanooga, TN 37402