St. Lawrence Child CareCouncil

Referral Request Form

To request a free child care referral please complete this form and email it to:

or print and FAX it to (315) 394-6809

You may also mail or bring it to our office:

St. Lawrence Child Care Council

318 Ford Street

Ogdensburg, NY 13669

If you need assistance with this formplease call (315) 393-6474

For information about the different types of child care programs in St. Lawrence County visit the parent’s page of our website at

The information you providewill help our referral counselor search for child care services that best match your family’s needs.

You will receive information on at least three child care programs and educational materials that match the criteria you provided to our referral counselor.

The SLCCCdoes not provide recommendations to child care providers. The provider names and information you receive are referrals. Just because a program is registered or licensed it does not always ensure quality care. We encourage you to visit several providers before making your final choice. Ask for references and contact them to see what they think about the provider you are thinking of using. You are the best person to decide whether the provider and quality of the program is right for your child.

SLCCC employees will keep all customer information confidential. The Information you provide is used to give you individualized services and to gather statistical information. Specific customer data is kept private at all times. No personal information will be shared without your written consent.

If you have any questions or need assistance completing this form, please contact Jennifer Thompson at (315) 393-6474 or 1-800-246-5352. Our office is open and referrals are available Monday – Friday from 8:30am - 4:00pm

General Information

First Name / / Last Name /

Address (parent)

Street Address / / Apt # /
City / State / Zip Code / +4
Family Composition / Single Parent / Two Parent / Teen Parent
Foster/Guardian / Other ______
Mailing (if different than above)
Street Address / / Apt # /
City / State / Zip Code / +4

Contact Information

Home Phone / / Work Phone / ext.
Cell Phone / / Fax /
Email Address /
Please supply 2 phone numbers, if possible and your email address

Parent Information

Employer ______

Other Employer ______

Number of children:______Financial Assistance? YesNo

(Do You ReceiveAny Public Assistance?)

Location of Care Desired

Near Home / Near Work/School/Training / Near Child's School
Near Public Transportation / In Own Home

Child General Information

Name 1______Birthdate ______

Gender:MaleFemale

Name 2______Birthdate ______

Gender:MaleFemale

Name 3______Birthdate ______

Gender:MaleFemale

Name 4______Birthdate ______

Gender:MaleFemale

Date Care Needed:______Age(s) Care Needed:______

Care Needed: Full TimePart TimeBoth

Care Needed:Full YearSchool YearSummer Only

Days Care Needed

Day / Start Time / End Time / Day / Start Time / End Time
Monday / / / Monday / /
Tuesday / / / Tuesday / /
Wednesday / / / Wednesday / /
Thursday / / / Thursday / /
Friday / / / Friday / /
Saturday / / / Saturday / /
Sunday / / / Sunday / /

Extra Care Services

Drop In / 24-Hour / Before School
After School / Rotating/Shift / Temp/Emergency

Type of Care (See Types of Care Explanation on the Website)

Child Care Center / Family Child Care / Preschool Program
School Age Program / (FCC)Group Family Care

Environment

Smoke Free / Smoking / Pets
No Pets / Pool / Fenced Pool
Computer / Outdoor Play / Fenced Play Area
Wood Stove / Fireplace / Gym

Languages (Check the language(s) you want the provider to accommodate)

English / Spanish / American Sign Language
Chinese (Mandarin) / Chinese (Cantonese) / Creole
German / Russian

Special Needs (Check if you need your provider to accommodate any of the following for your child(ren)

Developmental Disability / Educational Disability / Special Care Needs
Wheelchair Access / Special Diet / Sign Language
Moderately Ill/Health Service / Transportation / Inclusive/Integrated
Itinerant / Gifted / Other (See Comments)
Medication – MAT (Check if you need your provider to administer medications)
NYS Approved to Give Medications / Not NYS Approved to Give Medications / Not Applicable

Program (Specify what type of program for your child(ren)

Universal Pre-K/Pre-K / Nursery School / Playgroup
Kindergarten / Head Start/Early Head Start / Special Education
Vacation/Holiday / Special Interest / Summer Recreation
SACC (School Age Child Care)

Additional Care Services (Check if you need care for any of the following)

Evening / Overnight / Weekend Mildly Ill/Sick
Snow Days / Respite Care / Rotating Schedule

Elementary School (Identify what school child will be attending if eligible)

______

Transportation (Identify if you need your provider to accommodate any of the following)

Transportation providedWalking distance to schoolNear Public Transportation

Statistics General

Parent’s Birthdate:______Family Size:______

Relation to Children:

FatherMotherGrandparentGuardianFoster Parent

Case Worker

Employment Status:

EmployedSeeking EmploymentAt HomeStudent

End Leave of Absence

Adults:

Single AdultTwo or more adults

Income Category (Check the line below based on your family size if your income is above or below the amount indicated)

Family SizeIncome (State guidelines)

1$21,660

2$29,140

3$36,620

4$44,100

5$51,580

6$59,060

7$66,540

8$74,020

______Above______Below

Child Health:Send information on Child Health Plus Other ______

Are children covered by health insurance? ____ Yes _____No

Referred by:

Child Care Provider / Department of Social Services / Other Public Agency
Private Agency/CBO / Relative/Friend / Employer
Phone Book / Media/Newspaper / Internet
SLCCC Website / Former Client / Other

Reason for Seeking Care

End Leave of Absence / Seeking Employment / Employment
Training/Education / Current Provider No Longer Available / Child's Needs
Parent's Needs / Dissatisfied with Care / Other
No Data

Statistical Information (this is optional and data is used for statistical information only)

Are you Spanish/Hispanic/Latino? ______
What is your race? ______
What is your ancestry or ethnic origin? (i.e. Italian, African Am., etc.) ______
Doyou speak a language other than English at home? ______
If yes, what language? ______
How well do you speak English? ______

Your comments and/or suggestions are important to us. Please let us know if our services met or did not meet your needs. After you receive your referrals, please complete the parent referral service evaluation located on the Parent page of our website at

For more information concerning any child care program, please visit:

or call theNew York State Office of Children and Family Services Syracuse Regional Office at:

(315)423-1202

Thank you for choosing the St. Lawrence Child Care Council to help you in your child care search.

[Completed forms should be directed to and

Revised 08/14/12 BMS1