Child Care Referral Form
Form Translation Instructions
To translate the form into Spanish or another language (
Para traducir el formulario al español u otro idioma):
Open the form using Google Chrome web browser.
Download Chrome here.
(Abra el formulario con el navegador web Google Chrome.
Descarga Chrome aquí
.)
Anywhere on this form, right click and you will see a drop-down menu. (En cualquier lugar de este formulario, haga clic con el botón derecho y verá un menú desplegable.)
Select “Translate to …” (Selecciona "Traducir a ...".)
Choose the language you would like it to be translated to. (Elija el idioma al que le gustaría que se tradujera.)
Repeat steps 2-4 on each new form page. (Repita los pasos 2 a 4 en cada nueva página de formulario.)
Contact Details
Name (First & Last)
Relationship to child/ren
Please select...
Parent
Family Member
Legal Guardian
Primary Phone
Primary Phone
Home
Work
Cell
Secondary Phone
Secondary Phone
Home
Work
Cell
Would you like to receive
thread
notifications via text?
Yes
No
Email
Region
Please select...
Southeast
Southcentral
Northern
Southwest
Primary Address
City
State
Zip Code
Is your primary address the preferred vicinity for your child care program search?
Yes
No
Please add a secondary address for your child care program search area.
Secondary Address
Home
Work
Other
Region
Please select...
Southeast
Southcentral
Northern
Southwest
Secondary Address
City
State
Zip Code
Client Household Statistics & Demographic Information
Household Statistics
Please specify your family size and how many children and adults live in your household.
Family Size
Please select...
1
2
3
4
5
6
7
8
9
10
Adults
Please select...
1
2
3
4
5
6
7
8
9
10
Children
Please select...
1
2
3
4
5
6
7
8
9
10
Financial Assistance
Please select any program(s) you are currently enrolled in.
(Skip this question if it does not apply to you.)
Please select...
Child Care Assistance Program
Tribal
Military
Native Corporation
Military Branch
Please select...
Air Force
Army
Coast Guard
Marines
Navy
Current Employment Status
Please select...
Employed
Seeking Employment
Student
Other
Other
Annual Household Income ($)
Demographics
How would you describe your gender?
Please select...
Male
Female
Non-binary
Non-gender
Prefer not to answer
How would you describe your race/ethnicity?
Please select...
American Indian or Alaska Native
Asian or Asian American
Black or African American
Hispanic/Latino
Native Hawaiian or other Pacific Islander
White or Caucasian
Two or More Races
Other
Prefer not to answer
Other
Children & Program Information
Children Who Need Care
Please provide information for all children in need of care.
Child Name
Date of Birth
Age
What schedule are you looking for?
Part-time
Full-time
After Hours / Extra Care Services
Please select...
Weekend Care
Part Time Care
Rotating Schedule
Drop in / Temporary Care
Would you like to specify special needs accommodations for a child listed on this form?
Yes
No
Special Needs Accommodations (
Check all that apply
.)
Asthma & Allergy
Autism & Sensory
Emotional & Behavioral
Speech & Language
Cognitive Delay
Shots & Medications
Physical Impairment
Wheelchair Accessible
Other ADA Adaptive Equipment
Feeding Tubes
Other
Please provide additional notes regarding your child's needs.
Program Information
Please provide specifics on child care programs of interest.
What type of child care program are you searching for at this time?
Child Care Center
Family Child Care Home
Group Home
Head Start Program
Preschool Program
School Age Program
Summer Camp Program
Learn more about types of programs
What is your preferred day & time(s) for child care?
Transportation Information
Will your child need transportation from school to child care?
Yes
No
School Name
Additional Information
Will your child need care outside of normal care hours (weekends, after hours, etc.)?
Yes
No
Comments:
Environmental Needs
(Check all that apply
.):
Faith Based Program
Curriculum Based
What primary language does your child speak?
Please select...
English
Spanish
American Sign Language
Athabascan
Chinese
French
German
Hmong
Inupiaq
Japanese
Korean
Laotian
Russian
Samoan
Tagalog/Filipino Dialect
Tlingit
Yupik
Other Language
Does your child speak a secondary language?
Yes
No
Secondary language
Contact thread