You may conduct your own
    online child care search by
    going to the link below.
 

 

 
 


Early Start Child Care Resource & Referral Agency
Parent Intake Form

Have you ever used our services before?

Remember to inform consumer of the following:
Parent Referrals are a free service. Our agency can provide you referrals, NOT recommendations to registered and licensed child care programs. All of the information you give will be kept confidential.

In order to search for programs that best meet your needs I will need to ask you some questions and this process may take several minutes. Do you have time to complete this process now?

Based on this information we will search the database and provide you a list of referrals.


Name:
Physical or Mailing Address:

City:
State:
Zip:
County:
Phone (H): (C): (W):
Email:

Employer:
Employer Address:

Military or Military Dependant:

For Statistical Purposes Only (optional)

Age: Annual Household Income: Number of members in household:

Marital Status: 		Employment Status:

Are you currently receiving assistance with paying for child care?

Referred by: Reason for seeking care:
  Other reason for seeking care:

How many children need child care?
What date will you need child care to begin?
Child #1 Name
DOB:
Age:
Relationship to child:
Days: Sun Mon Tue
Wed Thu Fri Sat
Time: AM PM  to
         AM PM

Location:

Times other than normal work hours:

Type of care:

Extra Care Services:
Temp/Emergency Care
Transportation
Other:

Child's Health:
Immunizations up-to-date

Has Health Insurance:

Do you need any inclusion services?
(Inclusion = Services for children with special needs)


 Child #2 Name
DOB:
Age:
Relationship to child:
Days: Sun Mon Tue
Wed Thu Fri Sat
Time: AM PM  to
         AM PM

Location:

Times other than normal work hours:

Type of care:

Extra Care Services:
Temp/Emergency Care
Transportation
Other:

Child's Health:
Immunizations up-to-date

Has Health Insurance:

Do you need any inclusion services?
(Inclusion = Services for children with special needs)
How would you like to receive your referrals?
Phone Call
Mail
Fax
Email
Pick-Up
other


A Staff member will be contacting you within 1 business day with a list of

referrals.

 

We will be sending you information on what to look for in quality child care.

Some things to consider when looking are, child to staff  ratio, small group

size, staff has education in child development, program encourages family involvement, and staff has CPR/First Aid training.

 

The information packet will also include more detailed information  on the

types of care available, how to access state monitoring  reports, how to

file a complaint against a child care provider, as well as other helpful

information.

 

If you do not receive the written information within a week please contact

us back at 1-877-935-7575.

 

After we give you your referrals, we will be contacting you in approximately 

10-days to see how your search is going, should  you need any assistance

or need more referrals before then, please do not hesitate to call.

 

 
 


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