We can send you information
on child care centers, preschools and homes in your area that match your needs. With that we send information on child care regulations
and a checklist of things to look for when choosing child care. We send this out free of charge. We do ask for donations, and we are a
non-profit agency, so if you make a donation it’s tax deductible. We also send you a feedback form, and ask
that you complete and return that to us --which can be done anonymously.
Just complete the information
below and send it back. We can email a
referral to you.
Parent Intake Form Date of call______________ Date mailed______________
Caller's Name:
______________________________________ Relationship to child__________________
Address:______________________________________________________________County
__________
Phone:
_______________________ Phone
______________________Fax _________________________
Date
care is needed ______________ Hours
care is needed____________________________
DOB
Child 1 ________________ DOB Child 2 __________________DOB Child
3_______________
Days
of the week that care is needed:
MF Sat Sun
Mon Tues Wed
Thur Fri
___Center ___Family Child Care ___12 months ___School yr only ___Summer only
___Full
time ___Part time ___Drop-in ___Before / After School
___Evening ___Overnight ___Special Needs ___Other__________________
Area
/ other address area where care is needed
________________________________________________
School
District (for before & after school)
____________________________________________________
Other
needs or requests: __________________________________________________________________
New
Client______ Previous Client______ Previous Client / New Case ______
Optional Information: Employer
(mother) _____________________(father)________________________
[ ] Two adult household
[ ]Under 20 years [ ]Age
20-39 [ ] Number in Household
[ ] Single adult household [ ] Age 40-49 [
]Age 50 or over
Income: [ ]$10,00 or under [ ]
$10,000 - $29,000 [ ] $30,000 - $39,000 [ ]
$40,000 & up
Languages: [ ] English [ ] Spanish
[ ] Asian [ ] Other