Child Care Referral Form
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Para traducir el formulario al español u otro idioma):
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(Abra el formulario con el navegador web Google Chrome.
Descarga Chrome aquí
.)
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Repeat steps 2-4 on each new form page. (Repita los pasos 2 a 4 en cada nueva página de formulario.)
Contact Details
Name:
Relationship to child/ren:
Please select...
Parent
Family Member
Legal Guardian
How did you hear about
thread
?
Address:
City:
State:
Zip Code:
Is this the preferred address to search around for care?
Yes
No
Please add another address you would like to use for your child care search area.
Secondary Address:
City:
State:
Zip Code:
Phone Contact:
Secondary Phone Contact:
Email:
Financial Assistance
Do you need a Child Care Assistance subsidy to help pay for child care?
Yes
No
If you currently receive Child Care Assistance, please tell us if it's from the State of Alaska, Military, or Tribal.
Please select...
State of Alaska
Military
Tribal
Native Corporation
Military Branch
Please select...
Air Force
Army
Coast Guard
Marines
Navy
Client Household Statistics & Demographic Information
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
11
12
Number of Adults:
Please select...
1
2
3
4
5
6
7
8
9
10
Number of Children:
Please select...
1
2
3
4
5
6
7
8
9
10
11
12
Current Employment Status:
Please select...
Employed
Seeking Employment
Student
Other
Other:
Annual Household Income ($):
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
Please provide information for each child in need of care. Click "Add another child" to add additional children.
Child Name:
Date of Birth:
Age:
Preferred Days & Times
Please add times next to the days on which you need care.
For example, write
8
am - 5 pm
next to
Mondays, Tuesdays, and Wednesdays
.
Mondays:
Tuesdays:
Wednesdays:
Thursdays:
Fridays:
Saturdays:
Sundays:
Specify 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:
What date do you need care to start?
Preferred type of child care (
check all that apply
):
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
Is school transportation needed?
Yes
No
School Name
Preferred Language:
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
Tell us about any other community resource or parenting resource needs:
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