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.

Your Information:
 

First Name:
Last Name:
Address:
City:
State:
Zip:
Home Phone:
Alternate Phone:

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


You may be eligible to receive assistance paying for child care from your county department of social services if your household income falls within the
Subsidy Eligibility Guidelines
Family Size Max. Household Income
2 $28,000
3 $35,200
4 $42,400
5 $49,600
6 $56,800
7 $64,000
8 $71,200
Based on the above chart, are you:

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

Number of people residing in your household
Number of children that require child care:
 

Name: DOB: Sex: M F
Days: Mon | Tue | Wed | Thr | Fri | Sat | Sun | Hours:

Name: DOB: Sex: M F
Days: Mon | Tue | Wed | Thr | Fri | Sat | Sun | Hours:
Name: DOB: Sex: M F

Days: Mon | Tue | Wed | Thr | Fri | Sat | Sun | Hours:
Name: DOB: Sex: M F

Days: Mon | Tue | Wed | Thr | Fri | Sat | Sun | Hours:
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)

Center-based care
Family day care
Group family day care
Before/after school program
Camp (day or residential)
Nursery school
Head Start
Pre-kindergarten
Drop-in
Sick Care
School
Holiday/vacation
Information not available

Needs Special Services, Training, or Experience: (check all that applicable for each child)

Developmental delay/disability
Special diet
Language
Social services
Transportation
Health services
Non-smoking
Medication Needs

Family Composition: (check all that are applicable to each child)

Single Parent
Two-Parent

Teen Parent
Other

Reason For Care:

Employment
Subsidized job training
In-school/education
Current care ending
Dissatisfaction with current care
Supplemental Care
Moving
Relocation within company
End of leave of adsence
Personal/Needs of parent
Special needs of child
Other

Employment Information:

Main Employer: (enter 'Not Employeed' if currently out of work)
Location:

Secondary Employer:
Location:

Referred By: (check one)

Child care provider
Public agency
Professional/private agency
Relative/friend
Employer
Phone book
Media/newspaper, please indicate specific station or location
Other

Referral Information/Comments: