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Parent Referral Intake Form
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Parent Referral Intake Form
Parent Referral Intake Form
Parent Referral Intake Form
Please enable JavaScript in your browser to complete this form.
First Name
*
Last Name
*
Address
*
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
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California
Colorado
Connecticut
Delaware
District of Columbia
Florida
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Hawaii
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South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone
*
Email
*
1. Area or areas you are looking for child care:
*
Address listed above
Other Area 1
Other Area 2
Please list an address or intersection near the area you would like us to search. You can list multiple search areas.
Other Area 1:
Other Area 2:
2. Employer (and if applicable, spouse’s employer):
*
Used only to determine if your employer has a corporate contract with 4-C.
3. Family Status:
Two Parent
One Parent
Grandparent
Teen Parent
Foster Parent
Kinship Care
Relative
Other
Unknown
4. Children needing care:
*
1
2
3
4
Date of Birth/Expected Due Date:
*
Child 1 Date of Birth/Expected Due Date:
*
Child 2 Date of Birth/Expected Due Date:
*
Child 3 Date of Birth/Expected Due Date:
*
Child 4 Date of Birth/Expected Due Date:
*
Gender:
Male
Female
Unknown
5. Date Needing Child Care to Begin
*
6. Schedule Needing Care:
*
Early Morning Care (5:00 – 6:00 AM)
Daytime Care (6:00 AM – 6:00 PM)
Evening Care (6:00 PM – 10:00 PM)
Overnight Care (10:00 PM – 5:00 AM)
Weekend Care (Saturday and/or Sunday)
7. Daily start and end times for care:
*
8. Type of care:
*
Group Centers Only
Family Child Care Homes Only
Both Group Centers and Family Child Care Homes
9. Please list any special needs your child or children have:
10. Current Child Care:
None
Regulated Provider
Unregulated Provider
Relative
11. What is your total family size?
12. What is your household income?
$0 - $24,999
$25,000 - $39,999
$40,000 - $49,999
$50,000 - $59,999
$60,000 - $69,999
$70,000 - $79,999
$80,000 - $94,999
$95,000+
Choose not to answer
13. Is the County helping you pay for child care?
*
Yes
No
Choose not to answer
14. How did you hear about our service?
Friend/Coworker
Relative
Yellow Pages
Employer
Previous User
Job Center
Agency
Craig’s List
Provider
JobConnect
Counselor
WI Shares Office
Internet
YoungStar
Other
Restaino & Associates
Bunbury Concierge
15. What is your reason for seeking child care?
Family Leave
Looking for work
Work
School
Relocation
Unhappy with quality
Current care closing
Back-up care
Cost too high
Summer care only
Child/Parent Needs
Asked to leave
Other
16. What is your race or ethnicity?
White
Hmong
Hispanic or Latino
Asian (other than Hmong)
Black or African American
Two or more races
Other Race
American Indian or Alaska Native
Native American or Other Pacific Islander
Did Not Answer
Other Race:
17. How would you like to receive your referral information?
*
By mail at the address listed above
By Fax
By E-mail at the address listed above
Please include fax number:
18. Additional information / comments:
Submit
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