CCR&R Customer Intake

CCR&R Customer Intake
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 NameLast Name
Gender

FemaleMale
Parent Race(s)

AsianHawaiian/PacificUS Indian/AlaskanWhitePrefer not to answer
Are you of Hispanic, Latina/o, or Spanish origin?

YesNoPrefer not to answer
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Date of Birth

MonthDayYear
Date
Email
example@example.com
CHILD(REN) INFORMATION

Please list your youngest child first.
Child 1 Name

First NameLast Name
Child 1 Gender

FemaleMale
Child 1 Date of Birth

MonthDayYear
Date
Child 1 Race(s)

AsianHawaiian/PacificUS Ibdian/AlaskanWhitePrefer not to answer
Child 1 is s/he of Hispanic, Latina/o, or Spanish origin?

YesNoPrefer not to answer
Special Needs

YesNo
Days of the week care is needed (check all that apply):

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
Hours care is Needed

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option

GUARDIAN INFORMATION