Child Care Referral Request « Child Care Council – Rochester, NY

Child Care Referral Request

The Early Years MatterJune 30 2012
Please watch this new video about how important early care and learning is to children, families and the community. early_years_matter[1]
Annual Spring Conference | Save the Date!April 28 2012
Registration information can be downloaded here; Gretchen Kinnel Brochure Kinnell conference reg form Learn more about our guest speaker Gretchen Kinnell below: Gretchen Kinnell | Amazon.com Child Care Solutions Keynote Speakers | Gretchen Kinnell For more information, call 585‐654‐4720 (Monroe County), 315‐331‐5271 (Wayne County), or 585‐346‐6050 (Livingston County).

Having Fun with Music & MovementDecember 14, 2011
Children naturally connect music with body movement. We all know music provides children with multiple learning opportunities. However, when providing appropriate movement exercises with the music, children have the ability to discover their bodies and use their imaginations while activating many areas of the brain.
Health and Safety for Child Care CentersJanuary 1, 2012
This is not only a great training for new center staff but also a great refresher for current staff. It is a 15 hour class that covers all of the required topics. This is a competency-based curriculum which requires the successful completion of written and demonstration tests. To schedule or for more information call Ed [...]

General Information:

The information is intended for referral purposes only. We do not warrant the information concerning any provider, nor do we license, endorse or recommend any particular provider. Only you can determine whether the quality of care is appropriate for your child.

All information entered on this form is confidential.

If you do not receive information within two business days, please resubmit or call (585) 654-4720.

For more information concerning any program that may be of interest, please visit ocfs.state.ny.us or call the Office of Children and Family Services at (585) 238-8531.

Fields marked with an * are required in order to process your referral.
For the most accurate referrals, all fields must be completed.

Name of Person Needing Child Care Referral

First Name*
Last Name*
Street Address*
Unit Number
City*
State*
Zip Code*
Mailing address, if different

Contact Information

Please provide at least one contact number. Phone numbers should include area code.
Work Phone
Home Phone
Email Address*
Cellular Phone

Statistics of Person Requesting Child Care Referral

Age*
Relationship to Children*
Family Size*
Employment Status*
Adults in Household*
Have you used our service before?*
A parent or guardian is a member of the:
Army Marine Corps Navy Air Force
A Referral Specialist will contact you with information on military fee assistance programs you might be eligible for. An enhanced referral service is available for Army and Marine Corps families.
A Child Care Consultant will contact you to determine eligibility for an enhanced referral service and fee assistance through the National Association of Child Care Resource & Referral Agencies and the Department of Defense.
You may be eligible to receive assistance paying for child care if your household income is:
Income Category*
I would like information on financial assistance in my county.*
Monroe, Wayne, and Livingston Counties have different financial assistance programs and different income ranges, some up to or above these numbers.
*

Status for County Child Care Subsidy

Eligible for County Child Care Subsidy
Receiving County Child Care Subsidy On Waiting List for County Child Care Subsidy Not Eligible for County Child Care Subsidy Not Receiving County Child Care Subsidy Protective/Preventive/Foster Care

Reason you are seeking child care or a change in child care:

Child One General Information

First Name
Last Name
Gender
Birthdate*
Date Child Care Needed
Hours Child Care Needed (ex. "7am to 4pm")*
School District
Care Needed
Year Schedule
Days Care Is Needed
Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Type of Child Care Desired

Environmental Preferences

Smoke Free No Pets Smoking-No Preference Pets-No Preference
Please identify any pet/food allergies

Languages Needed

English Spanish American Sign Language Other
If other please specify which language(s)

Special Needs*

*In order to better serve you, please explain in the comment field below

Additional Comments

If you have additional comments that would be helpful in processing your referral request, please use the space below. You may also use this space to add additional children. Please include date of birth and any special needs.

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