CCR&R Customer Intake

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?

YesNo
Do you have an active application on the Waiting List to receive School Readiness services?

YesNo
GUARDIAN INFORMATION
Name*

First NameMiddle InitialLast Name
Gender*
Race
Are you of Hispanic, Latina/o, or Spanish origin?

YesNo
Are you currently homeless or residing in a shelter?

YesNo
Address*

Street Address or PO Box

Street Address Line 2

CityState

Zip Code
County
Are you a Leon or Gadsden County resident?

YesNo
Leon & Gadsden Co. Families Only: Do you currently have a safety seat for you child(ren)?

Yes, my child currently has an age appropriate car seat.Yes, but my child needs I seat appropriate for their age and size.No, my child does not have a safety seat.
Phone Number*
Please enter a valid phone number.
Date of Birth

MonthDayYear
Email*
CHILD(REN) INFORMATION

Please list your youngest child first.
Child No. 1*

First NameMiddle InitialLast Name
Sex*

MaleFemale
Date of Birth*

MonthDayYear
Date
Race
Are they of Hispanic, Latina/o, or Spanish origin?

YesNo
Special Needs?*

YesNo
Desired Curriculum (optional)
Days of Care Needed (check all that apply):*

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
Hours Care is Needed*

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
- Child No. 2
  
  First NameMiddle InitialLast Name
- Sex
  
  MaleFemale
- Date of Birth
  
  MonthDayYear
  Date
- Race
- Are they of Hispanic, Latina/o, or Spanish origin?
  
  YesNo
- Special Needs?
  
  YesNo
- Desired Curriculum (optional)
- Days of Care Needed (check all that apply):
  
  MondayTuesdayWednesdayThursdayFridaySaturdaySunday
- Times Care is Needed
  
  Hour Minutes
  
  AM/PM Option
  
  Until
  until
  Hour Minutes
  
  AM/PM Option
- Child No. 3
  
  First NameMiddle InitialLast Name
- Sex
  
  MaleFemale
- Date of Birth
  
  MonthDayYear
  Date
- Race
- Are they of Hispanic, Latina/o, or Spanish origin?
  
  YesNo
- Special Needs?
  
  YesNo
- Desired Curriculum (optional)
- Days of Care Needed (check all that apply):
  
  MondayTuesdayWednesdayThursdayFridaySaturdaySunday
- Times Care is Needed
  
  Hour Minutes
  
  AM/PM Option
  
  Until
  until
  Hour Minutes
  
  AM/PM Option
- Child No. 4
  
  First NameMiddle InitialLast Name
- Sex
  
  MaleFemale
- Date of Birth
  
  MonthDayYear
  Date
- Race
- Are they of Hispanic, Latina/o, or Spanish origin?
  
  YesNo
- Special Needs?
  
  YesNo
- Desired Curriculum (optional)
- Days of Care Needed (check all that apply):
  
  MondayTuesdayWednesdayThursdayFridaySaturdaySunday
- Times Care is Needed
  
  Hour Minutes
  
  AM/PM Option
  
  Until
  until
  Hour Minutes
  
  AM/PM Option
- Reason for Care*
  
  Change ProviderCost Too HighDisaster AssistanceEmployment/WorkingChild ExpelledMilitary/National Guard DeploymentRefuse to AnswerRelocationTraining/Education/Job SearchOther
- Your Relationship to Child(ren)*
  
  Parent/Step ParentGrandparentFoster ParentGuardianRelativeOtherPrefer Not to Say
- Problems You've Experienced Finding Care*
  
  Affordability/CostCare EndingCurriculum/ProgramLocation/TransportationSpecial NeedsType of CareNo OpeningsQualityScheduleOther
- Household
  
  Teen ParentOne AdultTwo AdultsPrefer Not to Say
- Referred By:
  
  Newspaper/Magazine AdBillboardBrochure/PosterDCFEmployer/BusinessChildren's ForumFriend/RelativeDivision of Early LearningLicensingRadio AdEarly Learning CoalitionSchool or ProviderTelevisionWebsiteWord of MouthOther
- Schedule Needed:*
  
  After SchoolBefore SchoolEmergency/Temporary CareEvening CareFull TimeFull YearOvernightPart TimeSummer OnlySchool System WeatherSchool YearSwing Shift (4pm - 12am)Weekend Care
- Special Needs: (optional)
  
  Autism Spectrum DisorderADHD/ADDAllergies (severe)Asthma (severe)Behavioral DisorderCystic FibrosisDevelopmental DisorderDiabetesHearing ImpairmentMental Disability/DelayMedically ChallengedPhysical Disability/DelaySpeech/Language DelaySeizure DisorderVisual ImpairmentOther
- Provider Type: (optional)
  
  Child Care CenterFamily Child Care HomePrivate SchoolPublic SchoolVPK-SISInformalLarge Family Child Care HomeCharter Public School
- Provider Programs I'm Interested In:*
  
  VPK ProviderSummer VPK ProviderSchool Readiness ProviderAfter SchoolBefore SchoolEarly Head StartHead StartKindergartenPlaygroupTeen Parent ProgramSchool AgeSummer CareSick Child Care (Mildly Ill)Camp
- Environment: (optional)
  
  EnglishSpanishCreoleSign LanguageSmoke FreeWeb Cam on SiteNo TVLimited TV viewedPetsPool on SiteSeparate Play AreasTherapeutic ServicesVideo Monitoring
- To help you narrow down your search, which zip code(s) would you like to search in? Please list them below:
- Are you in need of information on additional community resources? Please check all that apply.
  
  After School ProgramsAssistive Technology for DisabilitiesAutism, ADHD/ADD, and other related challengesClothing AssistanceCounseling ServicesDiaper AssistanceEarly Head Start/Head StartEducation and EmploymentFatherhood Programs and ResourcesFood AssistanceHome OwnershipHousing (Shelters, Emergency, Temporary)Legal ServicesParenting & Family SupportPediatric Day Care (Medical)Speech/Language/Behavioral TherapyTransportationTutoring Services and ResourcesUtility/Crisis AssistanceOther
- Is there anything else you want to let us know to help you with your search?
- 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:

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

GUARDIAN INFORMATION

CHILD(REN) INFORMATION