Child Care Information Request
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Child Care Information Request
Client Status
Select one
New Client/Case
Previous Client/Case- Same Quarter New Services
Previous Client/Case - New Quarter
Referral Source
Select one
Online
Phone
Outreach Event
Send Information by
Select one
Email
Mail
Both
Information Sent
Select one
Yes
No
Did not want information
Information
Select a date that the information should be sent. You will receive a reminder.
Information requested by:
*
Select
Mother
Father
Foster parent
Grandparent
Relative
Case worker
Other
If other, please specify
Name
*
First
Last
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Borough
*
Select one
Brooklyn
Bronx
Manhattan
Queens
Staten Island
Phone
*
Email
Referral Information
The first two questions (family size & income) will be used to find out if you are eligible for subsidized child care.
Language Spoken at Home
Select one
English
Spanish
Both
Other
If Other Language Please Specify
Are You Hispanic/Latino?
Please select one
Did not answer
No, not Hispanic/Latino
Yes, Mexican, Mexican American, Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, other
If 'yes, other', please specify:
What is Your Race?
Please select one
Did not answer
White
Black or African American
American Indian or Alaska Native (please specify tribe)
Asian Indian
Native Hawaiian
Chinese
Filipino
Japanese
Other Asian (please specify)
Guamanian or Chamorro
Samoan
Other Pacific Islander (please specify)
Other race (please specify)
if 'other', please specify:
Family Composition
*
Select
Single parent
Two parent
Teen parent
Foster parent
Homeless/In Shelter
Legal guardian
Caller Declined to Answer
Other
If other, please specify
Reason for seeking care?
Family size
Number of children
*
Select
1
2
3
4
5
6
7
Family Income:
Select one
Less than $23,540
$23,540 - $31,860
$31,860 - $40,180
$40,180 - $48,500
$48,500 - $56,820
$56,820 - $65,149
More than $65,149
Employment Status
Select One
Employed
Seeking employment
Student
Returning from leave of absence
At Home
Subsidy/Voucher Status
Select one
Vouchers
Subsidy
Both
None
Are they on any public assistance?
Child/Children Needing Care
Childs Name
Sex
Male
Female
Birthdate
Childs Name
Sex
Male
Female
Birthdate
Childs Name
Sex
Male
Female
Birthdate
Childs Name
Sex
Male
Female
Birthdate
Childs Name
Sex
Male
Female
Birthdate
Childs Name
Sex
Male
Female
Birthdate
Childs Name
Sex
Male
Female
Birthdate
Please check the type(s) for which you would like information (all that apply)
Center-based Care
Summer Camp
Family/Group Family Child Care Provider
Pre-Kindergarten
Head Start
Kindergarten
Special Care Needs (Developmental/Educational)
After-School Program
Vacation/Holiday Program
ACS Network & Document List
HRA Jobs Centers to the information
Type of Special Needs Care; Please specify
Is there any other information you may need?
Have you contacted other agencies for information
Select
Yes
No
Agency name
Choose the zip codes where you need care below
Home Zip
Work Zip
Other Zip
How did you hear about us?
Select one
Television Station
Google
Bing
Yahoo
Internet Search
CHCF Website
Case Worker
888 #
Flier
311
Hospital
ACS
Outreach Event
Former CHCF Client
Newspaper
311
Child Care Provider/Program
Public Community Agency
Private Community Agency
Employer
Relative/Friend
Social Media
Inbound Call
Local Department of Social Services
Phone Book
Other Child Care Resource & Referral Client
If Hospital, which?
Source of 888#
Source of 311#
Source of ACS
NACCRRA ID#
Questions or comments?
Upload Referral
If a paper referral.
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