Child Care Referral Request Online Form Children's Home + Aid CCR+R Program staff is available to provide assistance to you. Please complete the information below and select the appropriate program. We maintain the confidentiality of our customers. Your information will not be shared without your permission. * Required Fields Your Information * Your First Name:   * Your Last Name:   * Home Street Address:   * Home City:   * Home State:   * Home Zip:   * Home County:   * Home Phone Number:       Alternative Phone Number:           Work Cell Fax Number:       E-Mail Address:   * Employer:   * Is this your first referral request?     -- Choose One -- Yes No * Child Care Assistance Program Status     -- Choose One -- Currently on CCAP Not on CCAP Have Applied * Annual Household Income (Before Taxes):     -- Choose One -- Under $28,000 $28,001-35,000 $35,001-43,000 $43,001-49,000 $49,001-56,000 $56,001-62,000 $62,001-71,000 $71,001-75,000 $75,001-85,000 $85,001-99,000 $99,001-114,000 $114,001 + * How would you like your referrals delivered to you?     Mail Fax Email If you are relocating to the area or would like us to search near a different location than your home, please enter all known information below. Street Address:   City:   State:   Zip:   County:   Your Children's Information If you are pregnant, please enter due date.   Child's Name       *Child 1: D.O.B.: Gender: Male Female School Name: Child 2: D.O.B.: Gender: Male Female School Name: Child 3: D.O.B.: Gender: Male Female School Name: Child 4: D.O.B.: Gender: Male Female School Name: Child 5: D.O.B.: Gender: Male Female School Name: * Please list cities you want us to search: Special Needs (i.e. allergies, asthma, ADHD, cerebral palsy, etc) : Other Information: * Are any of these children Foster Children?     -- Choose One -- Yes No * Your relationship to Child(ren):     -- Choose One -- Father Mother Grandparent Guardian Relative Other When do you need care to begin?     (mm/dd/yy) * Days of Care Needed (please check all that apply):   Monday     Tuesday     Wednesday     Thursday   Friday     Saturday     Sunday * Earliest Drop-Off Time:     AM PM     * Latest Pick-Up Time:     AM PM * Type of Care Desired (please check all that apply):   School Age Program     Head Start Program     Child Care Center     Family Child Care Home   Preschool Program     ISBE Preschool for All     Before & After School Program Do you prefer the program to be Licensed or Licensed Exempt?     -- Choose One -- Licensed Only Exempt Only Either Extra Care Services Needed (please check all that apply):       Before School     After School     24 Hour Care     Drop In   Rotating Work Schedule     Temp/Emergency Care   Does your child need transportation?     No To/From Home To/From School Environment Preferences (please check all that apply):       No Pets     Wheelchair Accessible   * Languages (please check all that apply):       English     Spanish     American Sign Language   Other Languages:   Number of miles you are willing to travel:     0-5 6-10 11-15 16+ From:     Home Second Location Statistical Information This information will solely be used for statistical purposes in order to understand our community needs better. * Your age range:     19 & under 20 & over     * Family Size (including yourself):     * Adults in Household:     Single adult in household 2 or more adults in household * Reason for Needing Care:     Employment Education Relocation Work Related Parent Needs Child Needs Special Needs Dissatisfied with Current Provider No Provider Available Other * How did you hear about our services:     Phone Directory Subsidy Unit Internet Site TV Public Event Provider CCR&R System Friend/Relative Newspaper Agency Employer Radio Previous User Other Ethnicity:     Non-Hispanic Mexican American/Chicano Puerto Rican Cuban Other (please specify)     Other:     Race:     Caucasian-Hispanic African American American Indian or Alaska Native Asian Indian Native Hawaiian Chinese Filipino Japanese Vietnamese Other Asian Guamanian or Chamorro Samoan Other Pacific Islander Other Race (please specify)     Other:     Languages spoken at home:     There may be a fee for the service. (A copy of our fee policy is available upon request) Childcare referral fees will be based on a sliding fee scale. The sliding fee scale takes into consideration annual income and family size. The fees range from free to $30. Disclaimer: Childcare referrals are not recommendations to a specific provider. The Child Care Resource & Referral program (CCR&R) does not license, monitor, nor endorse childcare Providers. To determine if a licensed provider has had any founded licensing complaints, call the Day Care Information Line at 1-877-746-0829. The CCR&R recognizes that all client records regarding children and other persons served are confidential. The CCR&R has a complaint policy developed to ensure the well-being of children in any child care program listed with us and to give clients the opportunity to file complaints regarding CCR&R staff. (Copies of the policies available upon request)