Resource & Referral Customer Intake Form

 

 

 

 

Please fill out the following form as completely as possible. Once you submit your form, a representative should contact you within 24 business hours.

*Fields in red are required.

Applicant Information
Last Name:
First Name:
Email Address:	A value is required.Invalid format.
Date of Birth:
Gender:	Male Female
Address:
City:
Zip:	A value is required.Five Digit Zip Code Required
Phone:
Nearest Major Intersection to Where you Want your Child to Receive Care:
Intersection Nearest to:	Home Work Family Member Other
Employment Information
Employer:
Employer Address:
City:
Zip:
Employer Phone:
Other Information
Reason for Care:	Select One Customer Asked to Leave Program Caregiver No Longer Available Cost Too High End Leave of Absence Working Special Needs Unhappy with Quality Relocation Training/Education Hurricane Disaster Refuse to Answer Other
Child Care Issues:	Select One Cost Care Ending Curriculum/Program Location/Transportation No Openings Quality Schedule Special Needs Type of Care Refuse to Answer None
Relationship to Child(ren):	Select One Parent/Step-Parent Foster Care Legal Custodian Relative Teen Parent Refuse to Share Other
Household Composition:	Select One 17 & Under Living Alone One Adult Two Adults More than Two Adults Refuse to Answer Other
Income:	Select One Below $9,999 $10,000-$14,999 $15,000-$19,999 $20,000-$29,999 $30,000+ Refuse to Answer
Referred By:	Select One Billboards Brochure/Poster DCF Employer/Business Children'sForum Friend/Relative Yellow Page Office of Early Learning Licensing Radio Ad ELC School or Provider Television Web Site Word of Mouth Other
Children's Information (At Least One Child's Information is Required)
Child #1
Last Name:
First Name:
Date of Birth:
Gender:	Male Female
Special Needs:	Yes No
Transportation Needed:	Yes No
School Attending:
Days Needed:	M T W TR F S SU
Times Needed:	Early Morning Business Hours Evening Late Night
Child #2
Last Name:
First Name:
Date of Birth:
Gender:	Male Female
Special Needs:	Yes No
Transportation Needed:	Yes No
School Attending:
Days Needed:	M T W TR F S SU
Times Needed:	Early Morning Business Hours Evening Late Night
Child #3
Last Name:
First Name:
Date of Birth:
Gender:	Male Female
Special Needs:	Yes No
Transportation Needed:	Yes No
School Attending:
Days Needed:	M T W TR F S SU
Times Needed:	Early Morning Business Hours Evening Late Night
Child #4
Last Name:
First Name:
Date of Birth:
Gender:	Male Female
Special Needs:	Yes No
Transportation Needed:	Yes No
School Attending:
Days Needed:	M T W TR F S SU
Times Needed:	Early Morning Business Hours Evening Late Night
Additional Information
Provider Type:	Licensed License Exempt Registered Gold Seal Accredited
Programs:	Large Family Child Care Home Child Care Center Family Child Care Home Head Start Nanny/Au-Pair Play Group Voluntary Pre-K School Year School Age Program Voluntary Pre-K Summer Summer Camp Military
Schedule:	24 Hour Care After School Full-Time & Part-Time Before School Drop-In Care Emergency/Temporary Care Evening Care Full-Time Full-Year Morning Only Over Night Part-Time Rotating Summer Only Closed School System Bad Weather Days Weekend Care Vacation/Holidays School Year
Transportation Needs:	From Child's Home Near Public Transportation To Child's Home Transportation Provide to School Walking Distance to School
Environmental:	English Spanish Creole French Portuguese Russian Vietnamese Elevator Faith Based Center Fenced Yard Inclusionary Setting Special Needs No Pool No Pets Operation Child Care Outdoor Play Pet On Site Pool On Site Sick Child Care Offered Sign Language Smoke Free Spa/Hot-Tub On Site Teen Parent Program Wheel Chair Accessible Video Monitoring Webcam Medical Training
Enhanced Services	Computer Arts & Crafts Family Environment Field Trips Gymnastics/Dance Lessons Health/Social Services Homework Tutor Kindergarten Class Music Lessons On-Site Screenings Developmental Screenings Outdoor Sports Small Group Size Special Needs Enrolled Swim Lessons Therapeutic Services
Are You in Need of Financial Assistance for Child Care?:	Yes No
Financial Assistance:	None Negotiated Rates Sliding Scale Fees Sibling Discounts Scholarship-Available School Readiness Funded Other Voucher
Need to Apply for Florida KidCare? Click Here for More Information   For more information about childcare providers in Polk County, please call (863) 577-2450 or 1-800-843-9780.