Find Child Care

CONTACT INFORMATION

Today's Date
First Name
Last Name
Address
City
State
Zip code
County
Daytime telephone (with area code)
Other telephone (with area code)
Fax number (with area code)
E-mail address
Intersection closest to your home
Intersection closest to where child care is needed (if different)

How did you hear about Kent Regional 4C?
Advertisement Agency (other than FIA or United Way) Co-worker Child Link Don't Know Employer/Human Resources United Way 211 Workfirst orientation or other FIA caseworker Friend Internet Other Phonebook Provider referred parent Previous User Relative LSSM

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PARENT DETAILS The following demographic information is collected exclusively for our funding purposes as required by the United Way. The following questions are optional and kept confidential:
Gender    Male Female
Age        15-19 years 20-29 years 30-39 years 40-49 years 50-59 years 60-69 years 70-79 years 80+
Ethnic Origin/Race   Asian/Pacific Islander African American Caucasian Hispanic Native American Other
Household size    1 person 2 people 3 people 4 people 5 people 6+ people

Who is your employer?
Your spouse or partner's employer (if applicable)

Income $0 - $4,999 $5,000 - 9,999 $10,000 - 14,999 $15,000 - 19,999 $20,000 - 29,999 $30,000 - 39,999 $40,000 - 49,999 $50,000 - 74,999 $75,000 - 99,999 $100,000 and above
Schedule Request: First ShiftSecond Shift
Third ShiftFull-time Care
Part-time CareBefore school
After schoolRotating Schedule
WeekendsDrop-In
Temporary/EmergencyFull Year
School Year OnlySummer Only
Environment: Fenced YardPool/Lake
Near Public TransportationNo Pets
Has PetsSmoke Free
Special Services Desired: Provider will Provide TransportationSummer Camp
Elementary grades on-site
I would like my Child Care Provider to speak: SpanishSpanish Only
ArabicChinese
CroatianDutch
FrenchGerman
JapanesePortuguese
RussianSign Language
Vietnamese
Why do you need child care? (Check all that apply)   EmploymentTraining
RelocationEnd Leave of Absense
Extended Work HoursJob Travel
Job Schedule ChangeChild Needs
Parent NeedsSpecial Needs
DissatisfiedNo Provider

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CHILD DETAILS

How Many children need care?
What date do you need child care to start?

What is your child's date of birth?

Child 1
Child 2 (if applicable)
Child 3 (if applicable)

Do any of your children have special needs?
YesNo Please mark all special needs that apply to your child(ren): ADD/ADHDAsthma
AutisticBreathing Treatment
Cerebral PalsyCystic Fibrosis
DiabetesDown Syndrome
Drug Exposed (prenatal)Emotionally Impaired
EpilepsyFeeding Tube
Hearing ImpairedMentally Impaired
Feeding TubePhysically Handicap
Seizure DisorderSpeech Impaired
Spina BifidaVisually Impaired
Other, please specify

What type(s) of care are you interested? Family and/or Group HomesChild Care Centers
Preschools
Location of Child Care

Zip code where child care is needed:
Closest public elementary schools to where care is needed: (if known)

CHILD 1
What days and times does this child need care?
(Please be as specific as possible)

	Drop Off Time	Pick Up Time
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

CHILD 2
What days and times does this child need care?
(Please be as specific as possible)

	Drop Off Time	Pick Up Time
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

CHILD 3
What days and times does this child need care?
(Please be as specific as possible)

	Drop Off Time	Pick Up Time
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday