• Child Care Resource and Referral (CCR&R) Network Customer Intake Form

    Child Care Resource and Referral (CCR&R) Network Customer Intake Form

  • THIS IS NOT AN APPLICATION. To apply for School Readiness or VPK services, please visit the State's Family Portal at https://familyservices.floridaearlylearning.com/ 

  • Are you currently receiving child care assistance through ELC's School Readiness program?
  • Do you have an active application on the Waiting List to receive School Readiness services?

  • GUARDIAN INFORMATION

  • Are you of Hispanic, Latina/o, or Spanish origin?
  • Are you currently homeless or residing in a shelter?
  • Are you a Leon or Gadsden County resident?
  • Leon & Gadsden Co. Families Only: Do you currently have a safety seat for you child(ren)?
  • Format: (000) 000-0000.
  • Date of Birth
     - -

  • CHILD(REN) INFORMATION

    Please list your youngest child first.
  • Sex*
  • Date of Birth*
     - -
  • Are they of Hispanic, Latina/o, or Spanish origin?
  • Special Needs?*
  • Days of Care Needed (check all that apply):*
  • Until
    • Other Children Needing Care 
    • Sex
    • Date of Birth
       - -
    • Are they of Hispanic, Latina/o, or Spanish origin?
    • Special Needs?
    • Days of Care Needed (check all that apply):
    • Until
    • Sex
    • Date of Birth
       - -
    • Are they of Hispanic, Latina/o, or Spanish origin?
    • Special Needs?
    • Days of Care Needed (check all that apply):
    • Until
    • Sex
    • Date of Birth
       - -
    • Are they of Hispanic, Latina/o, or Spanish origin?
    • Special Needs?
    • Days of Care Needed (check all that apply):
    • Until
    •  
    • Reason for Care*
    • Your Relationship to Child(ren)*
    • Problems You've Experienced Finding Care*
    • Household
    • Referred By:
    • Schedule Needed:*
    • Special Needs: (optional)
    • Provider Type: (optional)
    • Provider Programs I'm Interested In:*
    • Environment: (optional)
    • Are you in need of information on additional community resources? Please check all that apply.

    • You may be eligible to receive assistance paying for child care. To see if you qualify, please visit Florida’s Early Learning Family Portal: 

      https://familyservices.floridaearlylearning.com/

    • All families receiving Child Care Resource and Referral services will be contacted to complete a voluntary survey to gauge your customer service experience with our office. All responses are anonymous and confidential and will not affect your services.

    • Should be Empty: