Oswego Child Care Referral Form
Oswego County Child Care Council
Referral Request Form
Please print and fill out in BLACK or BLUE ink or copy and paste and fill out on your computer.
General
To request a free child care referral please email POuderkirk@cnymail.com or print and fill out this form to our office : Attn: Pam Ouderkirk 157 West 1st Street Oswego, NY 13126
Most parents are not aware of the various types of care available. By entering the parent’s criteria into our database the counsellor can search for matching child care services. Educational materials will be sent to the parent matching the criteria given to the counsellor. ICP does not make recommendations or guarantee the quality of any program listed in our referral database. It is important that parents complete the steps found in “Guide to Choosing Quality Child Care” (put where it can be found on site) to choosing a quality child care program that meets their needs.
ICP staff will adhere to confidentiality. All client data is safeguarded at all times and kept private. The information is only for use in providing our CCR&R services and statistical information to our funder.
If you need any assistance completing this form, please contact Pam at 315.343.2344 x12
Monday - Friday, 8:30 a.m. - 4:00 p.m.
General Information
First Name _________________________ Last Name ________________________________
Address(parent)
Street Address ________________________________ Unit # ____________
City _________________ State _______ Zip Code ______________
Family Composition
__ Single Parent __ Two Parent __ Teen Parent
__ Foster/Gaurdian __ Other ______________________
Mailing (if different than above)
Street Address ____________________________ Unit # __________________
City _____________________ State ___________ Zip Code _______________
Contact Information
Home Phone ___-___-____ Work Phone ___-___-____ ext. _____
Cell Phone ___-___-____ Fax ___-___-____
Email Address ____________________________
Please supply 2 phone numbers, if possible and email address
Parent Information
Employer ______________________________
Other Employer ______________________________
Number of children: _______ Financial Assistance? __ Yes __No
(On Cash Public Assistance?)
Location of Care Desired
__ Near Home __ Near Work/School/Training __Near Child’s School
__ Near Public Transportation
Child General Information
Name 1 __________________________ Birthdate __________________
Gender: __ Male __ Female
Name 2 __________________________ Birthdate __________________
Gender: __ Male __ Female
Name 3 __________________________ Birthdate __________________
Gender: __ Male __ Female
Name 4 __________________________ Birthdate __________________
Gender: __ Male __ Female
Date Care Needed: ____________________ Age(s) Care Needed: __________________
Care Needed: __ Full Time __Part Time __Both
Care Needed: __Full Year __School Year __Summer 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 __ 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 __Educational __Special Care Needs
Disability Disability
__Wheelchair Access __Special Diet __Sign Language
__Moderately Ill/ __Transportation __Inclusive/Integrated
Health Service
__Itinerant __Gifted __Other (See Comments)
Mediation – MAT (check if you need your provider to administer medications)
__ NYS Approved to __Not NYS Approved to __Not
Give Medications Give Medications Applicable
Program(Specify what type of program for your child(ren)
__Universal Pre-K/Pre-K __Nursery School __Playgroup
__Kindergarten __Head Start/Early __Special Eduation
Head Start
__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 provided __Walking distance to school __Near Public Transportation
Statistics General
Parent’s Birthdate: ____________ Family Size: ____________
Relation to Children:
__Father __Mother __Grandparent __Guardian __Foster Parent
__Case Worker
Employment Status:
__Employed __Seeking Employment __At Home __Student
__End Leave of Absence
Adults:
__Single Adult __Two 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 Size Income(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 ________________
Currently covered on 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
__SCCP __Former Client __Regional 211
__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 (optional – this 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.) _____________________
Do you speak a language other than English at home? ________
If yes, what language? _____________________________________________
How well do you speak English? ____________________________
All client data is safeguarded at all times and kept private.
In approximately a week you will receive a follow up phone call to see how your search is going and also allow you to evaluate the services ICP provided to you.
Thank you for choosing Child Care & Development Council to assist you in finding a child care provider.
For more information concerning any child care program that may be of interest, please visit www.ocfs.state.ny.us or call the Office of Children and Family Services at (315)423.1202.