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2. Home-Based Childcare Network Interest Form

   Thank you for your interest in the Home-Based Childcare Network. Please complete the below interest form and a HCN Specialist will be in contact.

3. 
5. First Name*
6. Last Name*
8. Address1*
9. Address2
11. City*
12. State*
13. Zip*
15. Email Address*
16. Phone Number*
18. General Questions
20. Please check if you were referred by any of the agencies listed below.

    1. VA Dept of Education
    2. Norfolk Zoning - Dept of City Planning
    3. Navy FCC
    4. VDSS/VDOE Subsidy
22. Are you currently providing childcare in your home or the child's home for one or more children and receiving compensation? *

    1. Yes
    2. No
24. If you answered No to the above question, are you ready to make necessary changes within the home to ensure you meet home inspection requirements for licensing? *

    1. Yes
    2. No
    3. N/A
26. Are you currently employed during business hours (Monday - Friday 8:30am - 5:00pm)?*

    1. Yes
    2. No
28. If you answered Yes to the above, question, are you able to make yourself available during these hours to attend meetings and for home inspections? *

    1. Yes
    2. No
    3. N/A
30. Personal Considerations
32. Are you aware of the potential personal and financial cost associated with starting/maintaining a family day home?*

    1. Yes
    2. No
    3. Not Sure
33. Can you effectively manage your own business?*

    1. Yes
    2. No
    3. Not Sure
34. Are you willing to participate in ongoing trainings?*

    1. Yes
    2. No
    3. Not Sure
36. Do you have any health-related concerns that would prevent you from working with children?*

    1. Yes
    2. No
    3. Not Sure
37. Do you have a criminal background?*

    1. Yes
    2. No
    3. Not Sure
38. Does anyone in your household have criminal background?*

    1. Yes
    2. No
    3. Not Sure
40. Family Considerations
42. Does your family support the operation of a childcare program in your home?*

    1. Yes
    2. No
    3. Not Sure
43. Will your family support other children being in the home when they come home from school or work?*

    1. Yes
    2. No
    3. Not Sure
44. Will your own children be able to share you and your time with other children?*

    1. Yes
    2. No
    3. Not Sure
46. Home Considerations
48. Do you have permission from your landlord to operate a business if you do not own your home?*

    1. Yes
    2. No
    3. Not Sure
    4. N/A
49. Does your home have an area for diaper changing?*

    1. Yes
    2. No
    3. Not Sure
51. Neighborhood Considerations
53. Have you talked to your neighbors about operating a child care program in your home?*

    1. Yes
    2. No
    3. Not Sure
54. Will the noise of children playing outside affect your neighbors?*

    1. Yes
    2. No
    3. Not Sure
55. Is there space outdoors for children's activities or a space nearby for recreational activities?*

    1. Yes
    2. No
    3. Not Sure
Leave This Blank:


57. 1. Receive an email copy of this form.
58. Email address

    This field is not part of the form submission.

59. Submit Submit and Print

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