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  School-Age Child Care: B.A.S.I.C.S. application






B.A.S.I.C.S. APPLICATION
Please complete the following information; print all information. Please include area code.

Name:_____________________________Title:________
Agency:_________________________CCC/FCCH/GCCH
Address:________________________City:___________
Zip:____________County:_____________
Years of Operation:______________
Star Rating:________ Date of Evaluation:________
Ages of Children Served:_______Program Fee:_____
Number of School-Age Children Served:________
Total Number of Children Licensed for:________
Email:_________________________
Phone:_______________________Fax:______________
Home/Cell Number:______________________________
Is your program in a designated area? Yes or No
If licensed by DHS, who is your licensing counselor?________________ If cerfified by DOE, who is your counselor?_________________ If certified by DOE, are you participating in the STAR Rating System? Yes or NO

Please circle all of the following TOPICS that are needed.
*Training: Please specify:______________________
*Policies & Procedures (payment, scheduling, programming, sncaks,safety policies,....)
*Arts & Crafts
*Resources
*Drama/Theater *Music
*Language/Reading *Environment (Decor,...)
*Science/Nature *Gross Motor/Active Play
*Cultural Awareness *Cooking
*Staff Interactions *Office Supplies
*Staff Supervision
*Communication(child, parent, staff)
*Program Structure (schedules, programming)
*Staff Development
*Supplemental Equipment for child with special needs & training
*Other (please specify)_________________________
If financial assistance for supplies or equipment is requested & not listed above, please specify the amount and the supply description of the specfic item:________________
________________________________________________
$_________________

A PROGRAM BUDGET MUST ACCOMPANY THIS APPLICATION.

I certify that the above information is true and will allow TennSACA, through B.A.S.I.C.S., to possibly visit and monitor the program.
Signature:______________________________
Title:______________________________
Date:___________________________________

Fax to: 615-391-5338
Mail to:
B.A.S.I.C.S.
Tonya Bryson
236 Barker Road
Nashville, TN 37214





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