iCare-SCDSS: Site Licensing Form

Center Information

Center Name:
Program ID:

Address:
City:
State:
Zip Code:

Phone:
Fax:
Email:
Website:

Owners's Name:
Phone:
Fax:

Director's Name:
Phone:
Fax:

Licensed Total Capacity:
Federal Tax ID:
# of Active Children:
# of Workstation Licenses:

System Setup Information

Center Open Time:
Center Close Time:
Day Ending Time:

# of Data Terminals:
Cable Lengths: