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Online Referral Form
Online Referral Form
*Items in red are required.
Last Name *:
First Name *:
MI:
E-mail Address *:
Date of Birth:
Now
Gender:
Male
Female
Address:
City:
Zip:
Home Phone:
(
)
-
Other Phone:
(
)
-
Nearest Major Intersection to where you want your child to receive care?:
Employment Information
Employer:
Address:
City:
Zip:
Phone:
(
)
-
Other Information
Reason for Care *:
Customer asked to leave program
Caregiver no longer available
Cost too high
End leave of absence
Employment/Working
Parent/child's needs
Unhappy with quality
Relocation
Training/Education
Hurricane/Disaster
Refuse to answer
Other
Child Care Issues:
Affordability/Cost
Care Ending
Curriculum/Program
Location/Transportation
No Openings
Quality
Schedule
Special Needs
Type of Care
N/A or Refuse to Share
None
Relationship *:
Foster Parent
Legal Guardian
Parent/Step-Parent
Relative
Teen Parent
Refuse to Share
Other
Household *:
17 & Under/Living Alone
One Adult
Two Adults
More than two adults
Refuse to share
Income:
Below $9,999
$10,000-$14,999
$15,000-$19,999
$20,000-$29,000
$30,000+
Refuse to share
Referred By (Press Ctrl enter to select more than one):
Newspaper/Magazine
Billboards
Brochure/Poster
DCF
Employer/Business
Child Care Aware
Friend/Relative
Yellow Pages
Office of Early Learning
Licensing
Radio Ad
ELC
School or Provider
Television
Web Site
Word of Mouth
Other
Military
Children Information (*Information for at least 1 child is needed to conduct a search)
Child #1
Last Name:
First Name*:
MI:
Date of Birth *:
Now
Gender:
Male
Female
Special Needs (Press Ctrl enter to select more than one):
ADD/ADHD
Allergies (Severe)
Asthma (Severe)
Autism Spectrum Disorder
Behavioral Disorder (Severe)
Cystic Fibrosis
Developmental Delay
Diabetes
Hearing Impairment
Mental Disability/Delay
Medically Challenged/Delayed
Physical Disability/Delay
Speech/Languages DelayL
Seisure Disorder
Visual Impairment
Other
Transportation:
To
From
Days Needed (Press Ctrl enter to select more than one):
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Child #2
Last Name:
First Name*:
MI:
Date of Birth *:
Now
Gender:
Male
Female
Special Needs (Press Ctrl enter to select more than one):
ADD/ADHD
Allergies (Severe)
Asthma (Severe)
Autism Spectrum Disorder
Behavioral Disorder (Severe)
Cystic Fibrosis
Developmental Delay
Diabetes
Hearing Impairment
Mental Disability/Delay
Medically Challenged/Delayed
Physical Disability/Delay
Speech/Languages DelayL
Seisure Disorder
Visual Impairment
Other
Transportation:
From
To
Days Needed (Press Ctrl enter to select more than one):
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Child #3
Last Name:
First Name *:
MI:
Date of Birth*:
Now
Gender:
Male
Female
Special Needs (Press Ctrl enter to select more than one):
ADD/ADHD
Allergies (Severe)
Asthma (Severe)
Autism Spectrum Disorder
Behavioral Disorder (Severe)
Cystic Fibrosis
Developmental Delay
Diabetes
Hearing Impairment
Mental Disability/Delay
Medically Challenged/Delayed
Physical Disability/Delay
Speech/Languages DelayL
Seisure Disorder
Visual Impairment
Other
Transportation:
From
To
Days Needed (Press Ctrl enter to select more than one):
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Child #4
Last Name:
First Name *:
MI:
Date of Birth*:
Now
Gender:
Male
Female
Special Needs (Press Ctrl enter to select more than one):
ADD/ADHD
Allergies (Severe)
Asthma (Severe)
Autism Spectrum Disorder
Behavioral Disorder (Severe)
Cystic Fibrosis
Developmental Delay
Diabetes
Hearing Impairment
Mental Disability/Delay
Medically Challenged/Delayed
Physical Disability/Delay
Speech/Languages DelayL
Seisure Disorder
Visual Impairment
Other
Transportation:
From
To
Days Needed (Press Ctrl enter to select more than one):
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Additional Information
Provider Type* (Press Ctrl enter to select more than one):
Licensed
License Exempt
Registered
Gold Seal Accreditation
Programs* (Press Ctrl enter to select more than one):
Large Family Child Care Home
Child Care Center
Family Child Care Home
Head Start
Nanny/Au-Pair
Play Group
Voluntary Pre-K
School-Year
School Age Program
Voluntary Pre-K
Summer Camp
Military
Other Information* (Press Ctrl enter to select more than one):
Emergency Family Services/211
Other Referrals
Parent Education/Training Info
Hurricane/Disaster Assistance
Child Development/questions
Florida KidCare Insurance
Parenting Information
Child Behavior Questions
None
Schedule * (Press Ctrl enter to select more than one):
24 Hour Care
After School
Drop-In Care
Emergency/Temporary Care
Evening Care - After 7pm
Full-Time (More than 5 hours a day
Rotating (Work Schedule-Parent)
Summer Only
Closed School System
Bad Weather DAys
Weekend Care (Sat and Sun)
Vacation/Holidays
School Year
Are you in need of assistance paying for the cost of child care?:
Yes
No
Would you like your information mailed?:
Yes
No
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