* Today's Date:

* Is this the first time you have recieved a referral? Yes     No

* Home Phone:   Work/Other #:   Cell #:   Fax #:

Email Address:

* Are You Employed?

Yes
No
Student

Would you like an Internet user account to search for child care online?
If yes, please visit this page and click on the "Register" button.  This will allow you to create your own account with a personalized password to perform a basic search for child cares.

Yes
No

* Care is Requested: (check one)

Near Home
Near Work (Give location below)
Near Child's School (List school below)
Near Parent's School (List school below)
No Preference
Other (Please explain below)

Details:

Please complete the following information for all children needing child care:

* Starting Date Care is Needed:

Other Scheduling Needs: (check all that apply)

Full-time (30+ hrs/week)	Rotating Schedule
Part-time (less than 30 hrs)	Summer only
Full-year care	24-hour Care
School year only	After-school Care
Drop-in Care	Temp/emergency care
Before-school Care

* What type of facility are you looking for? (check all that apply)

Child Care Center (13 or more children)	School Age Program
(CCC) Tribal Licensed Program	Unlicensed School Age Program
Family Child Care (3-6 children)	Group Home Child Care (7-12 children)
Preschool Program	Unlicensed Sick Care
Unlicensed Summer Program	Unlicensed Drop-in Care

Do you have any needs/preferences regarding environment? (check all that apply)

Provider will toilet train	No pets at facility
Non-smoking facility	No vehicle transportation
Offers field trips	Outdoor activities
Outdoor play equipment	Preschool Program
Wheelchair accessible	Uses a structured curriculum
No TV	Summer Program

Do you need a provider who speaks a language other than English?

Yes
No

If yes, what language?

If you are looking for a provider with special needs experience, please specify need:

Often providers do not have frequent vacancies but maintain a waiting list. We encourage parents to look at all facilities that meet their criteria even thought they may not have an immediate opening.

Do you want your referral listing to include providers with waiting lists? Yes     No

Transportation Needs (Only if Required)

None

I require transportation from provider Please specify need: (check all that apply) To/from Kindergarten To/from child’s activities To/from child’s home Before and after School Transportation for family

I rely on public transportation

I need child care to be walking distance from school

I need family transportation

* What school(s) do/does your child(ren) attend?

1.

2.

3.

4.

* Who is providing your current care? (check all that apply)

No current care	Before/After school program
Family member	Preschool
Friend	Head Start
Nanny	Family/group child care
Child Care center	LUP/LUI

* Do you receive child care payment assistance?

No Assistance

Best Beginnings Scholarship (Family Connections)

TANF

Respite

Tribal Block Grant

Tribal TANF

Would you like information regarding child care payment assistance? Yes     No

* What is your family size? (Number of adults and children in your household)

Single Adult in Household

Two or More Adults in Household

* How did you hear about our services?(check all that apply)

Employer	Media: newspaper, radio, TV
Phone Book/Yellow Pages	Child care provider
Friend/relative	Brochure/poster
Tribal program	Previous User
Community agency	Internet/website
Unknown

* What is your reason for seeking child care? (check all that apply)

Work	Respite care
Current care closing	Current cost too high
Looking for work	Child's needs
Asked to leave	School/training
Parent's needs	Unhappy with quality of current care

Would you like a personal consultation on selecting quality child care? Yes     No

If you would like any parenting or child development information, please specify:

I would like to have my referral list: (check one)

Mailed to my address.

Emailed to me (Note: We cannot send email to AOL accounts).

Faxed to me.

I will pick it up on this date and time:

Please double-check your entries for accuracy, make any needed changes, then click "Submit Form". If you need to completely start over, click "Clear Form" (Be advised: this will clear everything entered on the form).