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Childcare Referral Request Form

** There is no fee for our Referral Service, but donations are welcome. ** .
**
To receive accurate referrals ALL information MUST BE COMPLETED.
Click the Send E-Mail Button when you are finished.

All information provided by our customers remains confidential to our agency. All information gathered is for statistical purposes only, and will not be shared outside of our office. [See Confidentiality Policy]

An Explanation of the Referral Process

To: Saginaw Valley Regional 4-C
NOTE:Our referral database covers Arenac, Bay and Saginaw Counties only. For providers in other areas please call the statewide number: 1-866-4childcare

Subject:

*Name:

* Your Age:
* Address:

Township:

*City:

* State:

* Zip:

*Phone: ###-###-####

Fax: ###-###-####

Best time to call:

*Email Address:

Check here if you would like your referral list emailed to you

Your Employer/School:

Other parents Employer/School:

Financial Assistance Does your family receive Financial Assistance from these programs?
(Check all that apply)
FIP/Cash Grant
Child Day Care Subsidy

What is your family size and income? (Please include self, spouse, children or other parenting home)

Child/Children Information

Child 1 First Name

Date of Birth

Date Care To Begin

Relationship to Child

Potty Trained?
Yes No

Child 2 First Name

Date of Birth

Date Care To Begin

Relationship to Child

Potty Trained?
Yes No

Child 3 First Name

Date of Birth

Date Care To Begin

Relationship to Child

Potty Trained?
Yes No

Child 4 First Name

Date of Birth

Date Care To Begin

Relationship to Child

Potty Trained?
Yes No

Child 5 First Name

Date of Birth

Date Care To Begin

Relationship to Child

Potty Trained?
Yes No

Child 6 First Name

Date of Birth

Date Care To Begin

Relationship to Child

Potty Trained?
Yes No

** If more space is needed, please continue children's information in the notes section at the bottom of this page **

Special Care Needs Are there any care needs that would require a provider to have special skills or training?
(Please indicate Yes or No)
Yes No

If "Yes" please explain

Which days will care be required? (Please check all that apply)

Monday Through Friday All Seven Days
Mon. Tues. Wed. Thurs. Fri. Sat. Sun.

Earliest expected drop-off time:
Latest expected pick-uptime:

Specific Care Wanted (may check more than one)
Center
Family Day Care Home
Group Day Care Home
Preschool
Camp
Before and After School Only

Type of Care Plan your looking for:

Type of Schedule:

Duration of Care Need:

What areas would you like searched? (please use the nearest sidestreet to your home, i.e. Franklin St X Truman Blvd.)

Near Home:

Near Work:

Near School:

Near Other:

What schools, if any, do the child attend?

Will the child need transportation to/from school?
Yes No

Why do you need childcare? (Please check all that apply)


Employment Return from leave of absence Job schedule change Child has special needs Training Extended work hours	Child needs to be with other children Dissatisfied with current caregiver Relocation Job travel Parent's personal needs No provider

How did you learn about 4C's referral service? (please select most appropriate)

Comments Please use the section below for any additional information or comments as necessary:

Referral lists are emailed within 1 business day.
If you have not registered for this service, the list may
take 2-3 days via United States Postal Service.

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