Child Care Resource and Referral Center

Intake Form

1.	Date:	Click here to enter a date.

2.	Name: Click here to enter text.

3.	Address: Click here to enter text.

Click here to enter text.

4.	Phone: Click here to enter text.

5.	For how many children do you need care (include ages): Click here to enter text.

Child #1	Age: Click here to enter text.

Child #2	Age: Click here to enter text.

Child #3	Age: Click here to enter text.

6.	Are you eligible for Child Care Subsidy? ☐ Yes ☐ No

7.	Family Composition:

☐ Single Parent

☐ Two Parent Household

☐ Teen Parent

☐ Foster Parent/Guardian

☐ Other (please explain): Click here to enter text.

8.	Type of care requested:

☐ Center-based

☐ Family/Group Family

☐ Informal/Exempt Home Provider

☐ In Child’s Home

☐ Day Camp

☐ Nursery School

☐ School Age

☐ Head Start

☐ Pre-K

☐ Kindergarten

☐ Mildly Ill Care/Sick Care

☐ Other: Click here to enter text.

9.	Special Services Requested:

☐ Identified developmental or educational disability

☐ Special medical, nutritional, or physical care needs

☐ Special diet

☐ Language spoken other than English

☐ Sign Language

☐ Transportation

☐ Wheel Chair Accessible

☐ Other: Click here to enter text.

10.	Time of Care:

☐ Full Time

☐ Part Time

☐ Temporary/Emergency

☐ Summer Vacation/Holiday

☐ Before/After School

11.	Non-Traditional Schedule:

☐ Evening

☐ Weekend

☐ Rotating Schedule

☐ Overnight

12.	Location of Care Requested:

☐ Near home

☐ Near work/school/training

☐ Near child’s school

☐ Public transportation

13.	Reasons for Care:

☐ Employment/Seeking employment

☐ Training/Education

☐ Parent Personal/Social needs

☐ Child Development/Social needs

☐ Current provider no longer available

☐ Dissatisfied with care

☐ Other: Click here to enter text.

14.	How were you referred? Click here to enter text.