INSTRUCTIONS: ARIZONA FAMILY CHILD CARE PROVIDER STATEMENT OF SERVICES (Form CC-221-PD)

Arizona child care providers use a form CC-221-PD to document the services their business provides. This document can be obtained from the website maintained by the Arizona Department of Economic Security.

Arizona Family Child Care Provider Statement Of Services CC-221-PD Step 1: In the first blank box, enter your last name, first name and middle initial.

Arizona Family Child Care Provider Statement Of Services CC-221-PD Step 2: In the second blank box, enter the date.

Arizona Family Child Care Provider Statement Of Services CC-221-PD Step 3: The first section concerns your business. Indicate with check marks which days you are open on.

Arizona Family Child Care Provider Statement Of Services CC-221-PD Step 4: Enter your opening time on the first blank line of this section, your closing time on the second blank line, and any comments on the third blank line. Indicate with a check mark whether or not you offer drop in service.

Arizona Family Child Care Provider Statement Of Services CC-221-PD Step 5: Indicate with check marks which age groups you accept.

Arizona Family Child Care Provider Statement Of Services CC-221-PD Step 6: Enter your full day and part day charges for all age groups, as well as defining what you consider "full day" and "part day."

Arizona Family Child Care Provider Statement Of Services CC-221-PD Step 7: Write in any other charges where indicated, note any absence policies and charges, and indicate whether you provide transportation or meals.

Arizona Family Child Care Provider Statement Of Services CC-221-PD Step 8: Note which holidays you are closed on.

Arizona Family Child Care Provider Statement Of Services CC-221-PD Step 9: At the bottom of the first page, write out your daily activities, planned schedule, material and equipment for children.

Arizona Family Child Care Provider Statement Of Services CC-221-PD Step 10: On the second page, document your education by indicating the highest grade level you have completed with a check mark. Provide all written explanations requested concerning your experience in providing child care, special skills or knowledge of child care, behavior or discipline methods used, hobbies and special interests, and a description of outdoor and indoor areas where child care occurs.

Arizona Family Child Care Provider Statement Of Services CC-221-PD Step 11: Sign and date the second page.