IMPORTANT: Because of the confidential nature of information given on this form, DO NOT send on internet. Please print form and send information by mail.

Applicants must: be a child care provider for a family day care program licensed by the state of Illinois. send a completed application to The Reading Group, 3011A Village Office Place, Champaign, IL 61822.

Applicant name ________________________________________________________

Address, City, Zip ______________________________________________________

Daytime telephone number _______________________________________________

Person serving as primary contact: _________________________________________

At any given time, how many adults supervise children at the home/care center? ____

Please indicate the number of children of each age who are in your care:

Infant to 1 year old ____ 2 years old ____ 3 years old ____
4 years old ____ 5 years old ____ Other _________________

What days and hours do you provide care?
What days and hours would be best for training?
When is the best time to contact you?

Please briefly describe your program and what you hope to gain from this training experience for you and the children in your care. Also mention any special needs you believe should be taken into consideration.

By submitting this information, I certify that the above is an accurate and complete disclosure of the requested information. I understand that any falsification of information will disqualify my eligibility for a fee waiver for this program.

Please return to:

The Reading Group "Building Blocks to Literacy" 3011A Village Office Place Champaign, IL 61822