RESOURCE AND REFERRAL CHILD CARE PROVIDER REQUEST * Indicates a Required Field, failure to fill out all required fields can result in an unsuccessful request submission Have you received services through ELCAC previously? If so, what program(s) and dates:*Are you in need of financial assistance to pay for child care?*1st Parent Last Name**1st Parent First Name*DOB *2nd Parent Last Name*2nd Parent First NameDOB *Residence Address:**City*State**Zip*Mailing AddressCityStateZipHome Phone*E-Mail* Family SizeAlong with the list of child care providers, you will receive additional information to help you locate quality child care. How would you like to receive this information?*Care Zone Zip Code: (Choose ate least two zip code areas)**Reason For Care**Referred By**Relationship to Child*First Child*Last Name**First Name**DOB Sex (m/f)Childs School (If school age) Transportation To and From School Hours of Care needed (list times and days of the week)Second Child (additional children available for input at the bottom of this form)Last NameFirst NameDOB Sex (m/f)Childs School (If school age) Transportation To and From School Hours of Care needed (list times and days of the week)CURRICULUM (OPTIONAL) High Reach High Scope Galileo Creative Curriculum Montessori DLM Early Childhood Express Bank Street Religious (All) Beyond Centers & Circle Time Waldorf Wee Learn Other ENHANCED SCHEDULES 24 Hour Care Emergency/Temporary Care School Year After School Evening Care Summer Only Before School Full Time Part Time Weekend Drop-In Care Vacation/Holidays SPECIAL NEEDS: (OPTIONAL) NOTE CHILD’S INITIALS IN BOXChilds InitialsSpecial needs (ADD/ADHD, Mental or Physical Disability, Speech or language, behavioral, seizures, vision impairments, etc..ENVIRONMENT: (OPTIONAL) Bilingual Sick Child Near Public Transportation Sign Language No Pets No Pool Smoke Free Teen Parent Program Transportation by provider Walking distance to school *PROGRAM: (YOU MUST CHOOSE ONE OR MORE) Child Care Center Family Child Care Home Headstart Large Family Child Care Pre-K Early Steps School Age Program VPK Summer VPK School Year COMPLETE THIS SECTION FOR ADDITIONAL CHILDREN THEN PRESS SUBMIT For each additional child, include their full name, DOB, sex (m/f), the child’s school (if school age), whether transportation is needed to/from school and what days of the week & hours care is needed.3rd Child4th Child5th Child6th ChildOPTIONAL: The state of Florida sometimes asks for information about people seeking child care such as do they work or are they in school or training. If you would like to help us with providing this information please complete the following fields.Employer Name, Full Address & PhoneTraining Facility Name, Full Address & Phone This iframe contains the logic required to handle Ajax powered Gravity Forms.
