Special Needs Intake Form

DISCLAIMER: All providers listed in LOCATE: Child Care are regulated or approved by the Maryland State Department of Education or certified by the Maryland Department of Health and Mental Hygiene. When LOCATE identifies child care program options for parents, it means only that the programs identified are regulated by the appropriate agency and have met the criteria that agency sets forth. The responsibility for providing LOCATE with accurate listings of regulated providers/programs rests with the appropriate agencies. Responsibility for selecting and employing a child care provider rests with each parent. LOCATE: Child Care cannot guarantee the quality of providers in its files and urges parents to carefully interview and check references before leaving a child in care. A referral from LOCATE does not constitute a recommendation as to the quality of care.
If you are looking for care for more than three children, please calls us at 800.999.0120

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* 1. Today's date

Enter:

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* 2. I have read and understand the disclaimer above.

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* 3. First Name:

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* 4. Last Name:

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* 5. Address

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* 6. City

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* 7. Zip code:

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* 8. Are you homeless?

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* 9. Email address

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* 10. Cell Phone

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* 11. Home Phone

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* 12. Work Phone

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* 13. Best way to reach you during the day:

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* 14. LOCATE has an enhanced service for families whose children need accommodations for cognitive, motor, medical, or social challenges. Will you need this service?

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* 15. Are you or your spouse an employee of   ?

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* 16. If Pepco, please enter your ID number here

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* 17. If you are an employee or student at University of Maryland College Park, please enter your nine digit ID number.

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