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Childcare Referral Intake Form

Fill in the appropriate information below for our records to proceed.
Name
Email
Last 4 Digits of SSN#
Address
Client Status
New
Previous
Military
City Zip Code:
Phone (H) (W) (C)
Mailing Address
If different from above		 Address/city/zip
Family Status


Employment Status


  Employer: [If Military: Name:
Rank: Deployed? Y N ]
  Employer: [If Military: Name:
Rank: Deployed? Y N ]
Location of Care Near Home Near Work/School Near Child School -
 
Days Care Needed: Start Time End Time
Monday
Tuesday
Wednesday
Thursday
     
Friday
Saturday
Sunday
  Child Name: DOB Male Female
  Child Name: DOB Male Female
  Child Name: DOB Male Female
  Care/Program Preference
  Type   Extra Services   Schedule Type
Center Based After School Full Time
Family Daycare Before School Part Time
School Aged Program Snow Day Summer Vacation/Holiday
Summer recreation     Temp/Emergency
        Evening
        Weekend
        Overnight
  Pets OK? Y N
 
  Special Needs
Special Diet
Phys./Educ./Develop. Disabilities
Moderately Ill/Health Services
Needs provider to give medication
Not Applicable
  Total Adults in Household
Total Children Childrens Age/s
Your relation to child Mother Father Foster Parent/Gaurdian Grandparent Case Worker
 
  Your Age Range   Income Range   Childcare Subsidv
Under 20 yrs Family size 1 =/< $20,420 DSS Subsidy Eligible?
20-29 yrs Family size 2 =/< $27,380 DSS Contact Info Given?
30-39 yrs Family size 3 =/<$34,340    
40-49 yrs Family size 4 =/<$41,300    
50 yrs or over Family size 5 =/<$48,260    
    Family size 6 =/<$55,220    
    Family size 7 =/<$62,180    
    Family size 8 =/<$69,140    
    Above NYS 200% of Poverty    
Child Health
Child is fully immunized Referral given
Child has health care provider Did not want referral information  
Child has health insurance      
Who Referred to JLCP
Child Care Provider Walk In
Local DSS Prior Contact
Relative/Friend Public/Private Agency
Phone Book CCR&R Website
Media/Newspaper Employer
Internet Search Ft. Drum
Reason for Seeking Care Now
Starting/Seeking Employment Dissatisfied with Current Care  
Current Care ended Other
End of Leave of Absence      
Childs Race
African American
Asian
Caucasion
Hispanic
Multi Ethnic
Native American
 

Community Action Planning Council of Jefferson County, Inc.
518 Davidson St. | Watertown, NY 13601
Phone: (315) 782-4900  |  Fax: (315) 788-8251
CAPC is a United Way Partner