Parent Referral Intake Form

Fields marked with an asterisk (*) are required.
First Name: *
Please enter the First Name.
Last Name: *
Please enter the Last Name.
Address: *
Please enter the address.
City: *
Please enter the City.
State: *
Please select a state.
ZIP: *
Please enter the zip.
Phone Number: *
Please enter a valid phone number
Email: *
Please enter valid email address.
1. Area or areas you are looking for child care: *
Please list an address or intersection near the area you would like us to search. You can list multiple search areas.


Please enter valid input.
Other Area 1:
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Other Area 2:
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2. Employer (and if applicable, spouse’s employer): *
Please enter valid input.
3. Family Status:







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4. Children needing care:
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Date of Birth/Expected Due Date: *
Please enter valid input.
Gender: *
Please enter valid input.
Date Care is Needed: *
Please enter valid input.

Date of Birth/Expected Due Date:
Please enter valid input.
Gender:
Please enter valid input.
Date Care is Needed:
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Date of Birth/Expected Due Date:
Please enter valid input.
Gender:
Please enter valid input.
Date Care is Needed:
Please enter valid input.

5. Schedule Needing Care: *


Please enter valid input.
6. Daily start and end times for care: *
Please enter valid input.
7. Type of care: *

Please enter valid input.
8. Please list any special needs your child or children have:
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9. Current Child Care: *


Please enter valid input.
10. What is your total family size?
Please enter valid input.
11. What is your household income?







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12. Is the County helping you pay for child care?
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13. How did you hear about our service?















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Other:
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14. What is your reason for seeking child care?











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15. What is your race or ethnicity?








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Other Race:
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16. How would you like to receive your referral information? *

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Please include fax number:
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17. Are you interested in receiving a monthly e-newsletter for families and additional child development information?
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18. Additional information / comments:
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  • Any additional questions or concerns? Please contact us: 608-271-9181 or 1-800-750-KIDS

We will send you your customized referral listing within 1 business day!