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© 20 PRO Prog Progr PUR The p INS Indica A A SUB Mail c Sign I verify that m 15. National OGRAM IN gram Ident ram Name: RPOSE purpose of the Provide the Inform NAE Program S STRUCTIO te each of the m Appendix 1 Appendix 2 Appendix 3 Appendix 4 Appendix 5 Appendix 6 Appendix 7 Appendix 8 Appendix 9 Appendix 10 Appendix 11 Program incidents Any suspensio Any incident th The de A critic transp Any un facility Any su progra BMISSION completed for NAEYC Ac Attn: Qualit 1313 L Stre Washingto nature y that the informa my program’s purs _________ Signature Association f NFORMAT ification Self Report for e NAEYC Acad EYC of major c Standards, Eligi ONS major changes yo Change in P Change in t Change in G Change in L Change in P Change in O Merger with Addition of Addition of Deletion of Legal Actio m staff must sub s that may imp on or revocati hat did or cou eath of any chi cal injury to any ported by the E nusual incident y alone) uspected physi am. N INSTRU rm to: cademy ty Assurance eet NW, Suite n, DC 20005-4 ation submitted in rsuit of NAEYC A ____________ for the Educa TION rm is to: demy with the m changes that m bility Requirem ur program has e Program Name the Designated General Progra Location (Pag Physical Facilit Owner/Vendor h Another Prog a New Age Ca Satellite Locat Satellite Locat n/Court Order bmit the 72- Ho act program qu on in program uld have comp ld from any cau y child that res mergency Med t involving a lac ical or psycholo UCTIONS 500 4101 Em n this form is acc Accreditation will ____________ ation of Young most up-to-date may affect the p ments, and Can experienced belo e (Page 2) d Program Adm am Information es 5-6) ty (Page 7) (Page 8) gram (Pages 9 ategory Not Pre ion(s) (Page 1 tion(s) (Page 1 (Page 15) our Notification uality status. NOTIFY W m’s license or promised the e use ults in the child dical Response ck of supervisio ogical abuse of mail complete qualitya curate. If false o cease and/or my _________ g Children. A e programmati program’s ability ndidacy Require ow and complete ministrator (Pag n Including Con -10) eviously Served 3) 14) n form if the pro WITHIN 72 HO regulatory sta essential heal d being admitte e team, program on (such as bu f a child at the d form to: assurance@nae or misleading info y program’s curre ________ Title All rights reser c information. y to meet or m ements. e the applicable a ge 3) ntact List (Page d (Pages 11-1 ogram experien OURS atus th or safety of ed to a hospital m, parent, or ot t not limited to program or by eyc.org ormation is ever p ent accreditation ____________ NAEY rved. P aintain the 10 N appendix. e 4) 2) nces any of the f any child, su Emergency R ther individual) a child being l an individual t Fax complete (202 provided to the N n may be revoked ____________ C Self Program ID#: NAEYC Early C e following critic uch as but not Room for treatm eft unattended that the child m ed form to: ) 232-1720 NAEYC Academy d. ______ Report Childhood cal t limited to: ment (whether or leaving the met through the y, I understand t
15

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Page 1: EditsToSelfReport 9.13.10 12 - naeyc.org · or the Educa IN PRO dence and offici ... or play area. ire, sanitation © 20 App Curr ... EditsToSelfReport_9.13.10_12.45 ...

© 20

PRO

Prog

Progr

PURThe p

••

INSIndica

• A• A

SUBMail c

SignI verifythat m

15. National

OGRAM IN

gram Ident

ram Name:

RPOSE purpose of the • Provide the• Inform NAE

Program S

STRUCTIOte each of the m

Appendix 1

Appendix 2

Appendix 3

Appendix 4

Appendix 5

Appendix 6

Appendix 7

Appendix 8

Appendix 9

Appendix 10

Appendix 11

Programincidents

Any suspensioAny incident th

• The de• A critic

transp• Any un

facility• Any su

progra

BMISSIONcompleted for

NAEYC AcAttn: Qualit1313 L StreWashingto

nature y that the informa

my program’s purs_________Signature

Association f

NFORMAT

ification

Self Report fore NAEYC AcadEYC of major c

Standards, Eligi

ONS major changes yo

Change in P

Change in t

Change in G

Change in L

Change in P

Change in O

Merger with

Addition of

Addition of

Deletion of

Legal Actio

m staff must subs that may imp

on or revocatihat did or coueath of any chical injury to any

ported by the Enusual incidenty alone) uspected physiam.

N INSTRUrm to: cademy ty Assurance eet NW, Suite n, DC 20005-4

ation submitted inrsuit of NAEYC A____________

for the Educa

TION

rm is to: demy with the mchanges that mbility Requirem

ur program has e

Program Name

the Designated

General Progra

Location (Pag

Physical Facilit

Owner/Vendor

h Another Prog

a New Age Ca

Satellite Locat

Satellite Locat

n/Court Order

bmit the 72- Hoact program qu

on in programuld have compld from any cauy child that resmergency Medt involving a lac

ical or psycholo

UCTIONS

500 4101

Em

n this form is accAccreditation will ____________

ation of Young

most up-to-datemay affect the pments, and Can

experienced belo

e (Page 2)

d Program Adm

am Information

es 5-6)

ty (Page 7)

(Page 8)

gram (Pages 9

ategory Not Pre

ion(s) (Page 1

tion(s) (Page 1

(Page 15)

our Notificationuality status.

NOTIFY Wm’s license or promised the euse ults in the child

dical Responseck of supervisio

ogical abuse of

mail completequalitya

curate. If false ocease and/or my

_________

g Children. A

e programmatiprogram’s abilityndidacy Require

ow and complete

ministrator (Pag

n Including Con

-10)

eviously Served

3)

14)

n form if the pro

WITHIN 72 HOregulatory sta

essential heal

d being admittee team, programon (such as bu

f a child at the

d form to: assurance@nae

or misleading infoy program’s curre ________ Title

All rights reser

c information.y to meet or mements.

e the applicable a

ge 3)

ntact List (Page

d (Pages 11-1

ogram experien

OURS atus th or safety of

ed to a hospitalm, parent, or ott not limited to

program or by

eyc.org

ormation is ever pent accreditation

____________

NAEY

rved.

P

aintain the 10 N

appendix.

e 4)

2)

nces any of the

f any child, su

Emergency Rther individual)a child being l

an individual t

Fax complete(202

provided to the Nn may be revoked____________

C Self

Program ID#:

NAEYC Early C

e following critic

uch as but not

Room for treatm eft unattended

that the child m

ed form to: ) 232-1720

NAEYC Academyd. ______

Report

Childhood

cal

t limited to:

ment (whether

or leaving the

met through the

y, I understand

t

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© 20

App

Previo

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Date

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If this

15. National

pendix 1:

ous Program N

Program Namename to appear

of change:      

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CHANGE

Name:          

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© 20

AppThe DNAEY

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15. National

pendix 2: Designated ProgYC with changes

mer Design

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w Designate

e:

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l:

Date:         /  

ct one of the fol

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C. Meets the experience

D. Does not mabove:

Association f

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nated Progr

ed Program

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llowing options

st a baccalaure, or manageme

n place to mee

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meet the qualifi

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et the qualificati

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IGNATEDble for receiving warification on Pro

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bed in A, B, or

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inistrators qual

n ECE, CD, ElE

n Option A with

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All rights reser

AM ADMIndence regardingator for more info

lifications.

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ge 3 of 15

d can update

tration,

strator

B, or C listed

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15. National

pendix 3:

eral Progra

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ram Phone Num

ram Email:      

ram Website:  

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are authorized toal contacts listed onal contacts for

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tact act

for the Educa

IN GENER

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r on the NAEYC

ministrator

hange in the Des

d on all correspodicated below wifor the program

o receive confidebelow, includingthe program hav

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Na

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RAL PROGR

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atic information frmed contact, will r

ct #2:

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All rights reser

ORMATION

accreditation anting secondary co

rom NAEYC. Prreplace existing a

Note that if an

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nd can update NAontact listed for y

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15. National

pendix 4:

e(s) of Loca

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ENDIX 4 IS CO

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ram returned to

n for Curre

for the location

he floor plan (in

he program’s liing inspections

ange

am Address

ill be posted on t

g Address

correspondence

m address

ONTINUED ON

for the Educa

E IN LOC

ge

:

a new, perman

to a temporary

to the original locarily changed its

o its original loc

nt Location

n in which your

ncluding meas

icense (if applics requirements

s

the NAEYC webs

e to the program.

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THE FOLLOW

ation of Young

ATION

nent location on

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cation, followin

n

r program curr

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site when a prog

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WING PAGE

g Children. A

n / /

/ /

elf Report must ba change to the p

g a temporary

rently resides:

any areas that c

cumentation ce

ram achieves NA

State:

Country

Fax:

Website

hanged

State:

Country

Phone:

All rights reser

.

and plans to

be submitted to cophysical facility o

relocation, on

changed in the

ertifying that the

AEYC Accreditat

:

e:

:

Self

rved. Pro

return to its ori

onfirm the end oor grounds, you m

/       /    

past 30 days,

e new location/

tion.

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Zip

Su

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ogram ID#:

iginal location o

of the relocation. must also comple

    .

including outdo

/facility meets f

ite/dept/floor:

p:

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ge 5 of 15

on

ete appendix 5.

oor play area.

fire, sanitation

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pendix 4:

rent Billing

used for invoice

ame as program

tion:           ndividual must ale the Designated

nization Name

et Address:

ty:          

l:

rent Shippi

used for the ship

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l:

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g Address

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m address

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for the Educa

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ATION Co

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Program Adminisendix 3 to update

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n Materials.

ailing address

g Children. A

ontinued

Billing ad

trator, Secondary the programs co

State:

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Phone:

Same as

State:

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Phone:

All rights reser

dress has not c

ry Contact, or an ontact list.

:

billing address

:

Self R

rved. Pro

changed

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Su

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ite/dept/floor:

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p:

ge 6 of 15

ppendix 2 to

not changed

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15. National

pendix 5:

e of Chang

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se describe the

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umentation

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ram planned reon on         /    planned renovatin/construction.

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for the areas t

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mporarily change

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at the program

enovations/con    /         .

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e to the physic

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YSICAL FA

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s completed on

ooding, vanda

ounds that has

e program resp

any areas that h

on certifying the

to the physical fa

All rights reser

d walls, added/

must be submitte

n / /

lism) on /

s occurred:

ponded:

have changed,

e new facility m

acility or grounds

Self

rved. Pro

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ed to confirm the

/ .

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heduled for

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dix 4.

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© 20

Ap

Nam

Nam

Date

Reas

Have

It is Accr

If this

15. National

ppendix 6

me of previous o

me of new owne

e of change:    

son for change

e family memb

important for threditation. Che

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owner/vendor:

er/vendor:        

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e:          

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nd the NAEYC nd Accreditatioinformation ab

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opy of all formson is acceptabor e-mail subm

gram name chan

for the Educa

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been notified of

vendor to undebelow to indica

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rammatic changrammatic chancritical incidents

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s submitted to le for submissiissions.

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al incidents accdays using the

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etain documentd a copy of sen

pendix 1.

All rights reser

No

a program formr is aware of al

t current versiod resources.

the NAEYC AUpdates. Standards and

cording to the ae Self Report fouality status wi

ary and secondto contact info

cy requirementfect a program’ccredited progra

tation verifying nt e-mail with d

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rved. Pro

mally pursuing l program resp

ons of the NAEY

cademy Webs

d Accreditation

appropriate timeorm. thin 72 hours u

dary contact of ormation should

ts (if applicable’s ability to movam.

the date of all date and time s

Report, Pag

ogram ID#:

or maintainingponsibilities.

YC Early Child

ite frequently a

Criteria and re

eframes.

using the 72 Ho

your program td be reported a

e) are no longeve forward in th

submissions. stamp informat

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APPE

15. National

pendix 7: e note the follow

If two or morresulting me

• If a currentlysubject to ad

of merger:      

rmation for

Program Name:

his program beYes: please ind

o

s program curre

Yes: Expiration o

et Address:

       

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o

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o

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et Address:

       

ENDIX 7 IS CO

Association f

MERGERwing NAEYC proc

re currently accrerged program. y accredited progdditional verificat

  /         /      

r Programs

         

een assigned adicate Program

ently accredite

Date:         /  

een assigned adicate Program

ently accredite

Date:         /  

         

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ently accredite

Date:         /  

ONTINUED ON

for the Educa

R WITH Acedures regardin

redited programs

gram merges withtion.

 

s that Have

a program ID nuID#:          

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THE FOLLOW

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e Merged

umber?

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WING PAGE

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R PROGRA

program, the exp

program that is n

All rights reser

AM

piration date of t

not currently accr

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rved. Pro

the program that

redited by NAEY

Suite/dept/floo

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Report, Pag

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© 20

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If this

15. National

pendix 7:

son for Me

se describe the

rmation for

ram Name:    

et Address:

       

up Informa

number of chil

number of Gro

Categories Serfant oddler/Two reschool ndergarten

results in the add

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MERGER

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1.) S

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Total

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number of Gro

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results in the add

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ldren enrolled a

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at satellite loca

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ew age category

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ATELLITEy Web site.

ation:

 

atellite location:

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ation:

 

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ON(S)

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t also complete a

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1.) S

Date

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2.) S

Date

Stree

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15. National

pendix 10about satellite lo

atellite Name:

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se indicate the

atellite Name:

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e reason for the

new location o

         

 

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TION OF SNAEYC Academy

e deletion of sa

of the children e

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ation of Young

SATELLITy Web site.

atellite location:

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site:

site:

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TION(S)

Suite

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/COURT On?

     

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outcome was.

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