Resource and Referral Customer Intake Form

Note: This is NOT the application to obtain help paying for child care. To see if you qualify for financial assistance, please visit the Coalition website at www.elcnwf.org.

1. Family Information

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1. Complete The Following Information: (Required.)

First Name: *

Last Name:

Address: *

City/Town: *

State: *

ZIP/Postal Code: *

Email Address:

Phone Number: *

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2. Zipcode you're seeking child care in:

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3. Additional Phone Number Where You Can Be Reached:

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4. How would you prefer to receive your custom child care listing, community resources, and other requested information?

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5. In Which County Do You Want Your Child To Receive Care:

Bay

Calhoun

Franklin

Gulf

Holmes

Jackson

Washington

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6. This Location Is Nearest To:

Home

Work

Family Member

Other (please specify)

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7. What Are Your Reasons For Seeking Child Care Information: (Required.)

Customer asked to leave program

Cost too high

End of leave of absence

Employment/Work

Parent/child needs

Unhappy with quality of current child care

Relocation

Training/Education

Hurricane/Disaster

Refuse to answer

Job Search

Caregiver no longer available

Other (please specify)

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8. Child Care Issues: (Required.)

Affordability/Cost

Care Ending

Curriculum/Program

Location

Transportation

No Openings

Quality

Schedule

Special Needs

Type of Care

Not Applicable

Refuse to Share

Other (please specify)

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9. Household: (Required.)

17 years old or younger and living on own

One adult

Two adults

More than two adults

Refuse to share

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10. Relationship To Child: (Required.)

Parent/Step Parent

Foster Parent

Legal Custodian

Relative

Teen Parent

Refuse to share

Other (please specify)

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11. Household Income:

Below $9,999

$10,000-$14,999

$15,000-$19,999

$20,000-$29,999

$30,000 or Higher

Not Applicable

Refuse to Share

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12. Referred By:

Newspaper/Magazine

Billboards

Brochure/Poster

Department of Children and Families

Employer/Business

Children's Forum

Friend/Relative

Yellow Pages

Office of Early Learning

Licensing

Radio Ad

Early Learning Coalition

School

Current Child Care Provider

Television

Web Site

Word of Mouth

Other (please specify)

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* 1. Complete The Following Information: (Required.)

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* 2. Zipcode you're seeking child care in:

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* 3. Additional Phone Number Where You Can Be Reached:

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* 4. How would you prefer to receive your custom child care listing, community resources, and other requested information?

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* 5. In Which County Do You Want Your Child To Receive Care:

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* 6. This Location Is Nearest To:

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* 7. What Are Your Reasons For Seeking Child Care Information: (Required.)

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* 8. Child Care Issues: (Required.)

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* 9. Household: (Required.)

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* 10. Relationship To Child: (Required.)

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* 11. Household Income:

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* 12. Referred By:

1. Complete The Following Information: (Required.)

2. Zipcode you're seeking child care in:

3. Additional Phone Number Where You Can Be Reached:

4. How would you prefer to receive your custom child care listing, community resources, and other requested information?

5. In Which County Do You Want Your Child To Receive Care:

6. This Location Is Nearest To:

7. What Are Your Reasons For Seeking Child Care Information: (Required.)

8. Child Care Issues: (Required.)

9. Household: (Required.)

10. Relationship To Child: (Required.)

11. Household Income:

12. Referred By: