Child Care Referral Intake Form
The Child Care Council connects parents seeking child care for their children with New York State regulated child care programs in Herkimer, Madison and Oneida counties. To receive a listing of child care programs in your area, complete and submit the following intake form.
*NOTE: The Child Care Council does not recommend nor endorse any child care program. Because selecting child care is ultimately a parent's responsibility, we encourage you to check references, interview providers and visit as many sites as possible to compare programs to your family's needs.
What should you look for when selecting a child care program for your child? Use our checklist of questions to help guide you as you determine the best child care program for your family.
Please complete all information requested; doing so will help our referral staff provide you with the most accurate child care referrral possible.
Email Address: How would you like to receive your referral? (Be sure to include complete contact information for the way in which you are requesting to receive your referral.): U.S. Mail Email Fax
Eligible to receive subsidy, but have not applied to do so (click here for more information on how to apply for subsidy) Not eligible; my household income exceeds maximum guidelines Eligibility application in process
Currently receiving subsidy
Name: DOB: Sex: M F Days: Mon | Tue | Wed | Thr | Fri | Sat | Sun | Hours:
Location of care: Near home Near parent's work or school Near child's school, list school district Specific Location Information:
Type of Care: (choose all that apply)
Needs Special Services, Training, or Experience: (check all that applicable for each child)
Family Composition: (check all that are applicable to each child)
Reason For Care:
Employment Information: Main Employer: (enter 'Not Employeed' if currently out of work) Location:
Secondary Employer: Location:
Referred By: (check one)
Referral Information/Comments: