Winston Prouty Center Child Care Referral Request

Please complete this form if you are interested in Winston Prouty Center's free child care referral services. The more information you provide, the better we hope to serve you. After we receive your information, our referral specialist will be in contact with you about next steps.

All of the information you provide is secure and confidential.

Please note: we provide information about program options; we do not provide recommendations.

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* 1. Please complete to the best of your ability.

Your name

Your date of birth

Home phone

Cell phone

Work phone

Name of person seeking child care information (if not you)

Address 1

Address 2

City

State

Zip

Region (town or county of residence)

Worksite location (town or county)

Employer

If you are an employee of the state of VT, Department

Spouse's name

Spouse's employer

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* 2. What town or towns would you consider for the location of the child care?

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* 3. When are the best times to reach you, and how would you prefer to be contacted (cell phone, home phone, etc.)?

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* 4. Child #1 information

Name

Date of Birth

Gender

Preferred child care setting

Desired start date of care

Days of the week care is needed

Start time

End time

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* 5. Child #2 information

Name

Date of Birth

Gender

Preferred child care setting

Desired start date of care

Days of the week care is needed

Start time

End time

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* 6. Please check all that apply regarding the situation of the parent or caregiver and children.

The caregiver(s) is working

The caregiver(s) is seeking work

The caregiver(s) is in school/a training program

The caregiver(s) is under 18

The child or caregiver(s) is homeless

The caregiver(s) is a grandparent

The caregiver(s) is deaf or hard of hearing

The caregiver(s) does not have access to transportation

The caregiver(s) prefers no pets in the child care setting

Other (please specify)

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* 7. Please check all that apply in relation to the child or children for whom you are seeking child care. This information is used in hoping to better meet the needs of the child or children in the child care setting.

Allergies (please explain)

Asthma

Deaf or hard of hearing

Special dietary needs (please explain)

Diagnosed special needs (please explain)

Other (please specify)

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* 8. What languages (other than spoken English) are used by the child or caregivers?

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* 9. Please answer the following:

	Yes	No	Not sure/don't know
Receive SRS subsidy (Social & Rehabilitative Services through DCF)	Receive SRS subsidy (Social & Rehabilitative Services through DCF) Yes	Receive SRS subsidy (Social & Rehabilitative Services through DCF) No	Receive SRS subsidy (Social & Rehabilitative Services through DCF) Not sure/don't know
Receive TANF and/or Rea	Receive TANF and/or Rea Yes	Receive TANF and/or Rea No	Receive TANF and/or Rea Not sure/don't know
Eligible and/or applied for child care subsidy	Eligible and/or applied for child care subsidy Yes	Eligible and/or applied for child care subsidy No	Eligible and/or applied for child care subsidy Not sure/don't know
Child is in Protective Services	Child is in Protective Services Yes	Child is in Protective Services No	Child is in Protective Services Not sure/don't know

Winston Prouty Center Child Care Referral Request

Question Title

* 1. Please complete to the best of your ability.

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* 2. What town or towns would you consider for the location of the child care?

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* 3. When are the best times to reach you, and how would you prefer to be contacted (cell phone, home phone, etc.)?

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* 4. Child #1 information

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* 5. Child #2 information

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* 6. Please check all that apply regarding the situation of the parent or caregiver and children.

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* 7. Please check all that apply in relation to the child or children for whom you are seeking child care. This information is used in hoping to better meet the needs of the child or children in the child care setting.

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* 8. What languages (other than spoken English) are used by the child or caregivers?

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* 9. Please answer the following:

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* 10. Please add additional comments