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Parent Referral Intake Form

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Parent Referral Intake Form

First Name *

Last Name *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

1. Area or areas you are looking for child care: *

Address listed above
Other Area 1
Other Area 2

Please list an address or intersection near the area you would like us to search. You can list multiple search areas.

Other Area 1:

Other Area 2:

2. Employer (and if applicable, spouse’s employer): *

Used only to determine if your employer has a corporate contract with 4-C.

3. Family Status:

Two Parent
One Parent
Grandparent
Teen Parent
Foster Parent
Kinship Care
Relative
Other
Unknown

4. Children needing care: *

1
2
3
4

Date of Birth/Expected Due Date: *

Child 1 Date of Birth/Expected Due Date: *

Child 2 Date of Birth/Expected Due Date: *

Child 3 Date of Birth/Expected Due Date: *

Child 4 Date of Birth/Expected Due Date: *

Gender:

Male
Female
Unknown

5. Date Needing Child Care to Begin *

6. Schedule Needing Care: *

Early Morning Care (5:00 – 6:00 AM)
Daytime Care (6:00 AM – 6:00 PM)
Evening Care (6:00 PM – 10:00 PM)
Overnight Care (10:00 PM – 5:00 AM)
Weekend Care (Saturday and/or Sunday)

7. Daily start and end times for care: *

8. Type of care: *

Group Centers Only
Family Child Care Homes Only
Both Group Centers and Family Child Care Homes

9. Please list any special needs your child or children have:

10. Current Child Care:

None
Regulated Provider
Unregulated Provider
Relative

11. What is your total family size?

12. What is your household income?

$0 - $24,999
$25,000 - $39,999
$40,000 - $49,999
$50,000 - $59,999
$60,000 - $69,999
$70,000 - $79,999
$80,000 - $94,999
$95,000+
Choose not to answer

13. Is the County helping you pay for child care? *

Yes
No
Choose not to answer

14. How did you hear about our service?

Friend/Coworker
Relative
Yellow Pages
Employer
Previous User
Job Center
Agency
Craig’s List
Provider
JobConnect
Counselor
WI Shares Office
Internet
YoungStar
Other
Restaino & Associates
Bunbury Concierge

15. What is your reason for seeking child care?

Family Leave
Looking for work
Work
School
Relocation
Unhappy with quality
Current care closing
Back-up care
Cost too high
Summer care only
Child/Parent Needs
Asked to leave
Other

16. What is your race or ethnicity?

White
Hmong
Hispanic or Latino
Asian (other than Hmong)
Black or African American
Two or more races
Other Race
American Indian or Alaska Native
Native American or Other Pacific Islander
Did Not Answer

Other Race:

17. How would you like to receive your referral information? *

By mail at the address listed above
By Fax
By E-mail at the address listed above

Please include fax number:

18. Additional information / comments:

CONTACT

5 Odana Court Madison, WI 53719
608-271-9181 1-800-750-KIDS
608-271-5380
[email protected]

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