Early Start CT Expansion RFA Endowment

Site Information

Total sum of score: 0

Please complete this application for the site for which you are applying. If you are representing an organization with multiple sites, you will need to complete a separate application for each site you are requesting Early Start CT spaces for.

Is this site licensed by the OEC?

Yes

1. Please select the type of license this site has (please check one):

DCCC (licensed child care center)

DCGH (licensed group home)

DCFH (licensed family child care home)

2. Please enter the sites 5-digit license number:

1. Provide the name of the public school system, private school, or municipal agency responsible for oversite of the program:

2. If your site doesn't have a license number or DCEX number check this box

3. Provide the license number or the DCEX number for this site here:

Organization Name

Site Name

Site Address

Site Town/City

Site Zipcode

Site Contact Name

Site Contact Email

Site Contact Phone

Program’s OEC Registry ID# (if applicable)

Does this program participate in the Child and Adult Care Food Program (CACFP)?

Yes (0 Points)

No (0 points) (This answer will not prevent you from being considered for funding, as there is a waiver process available for selected programs.)

	Data	Organization	Name	Address	Town/City	ZipCode	Contact Name	Contact Email	Contact Phone