* Please choose one of the following:
How would you like to receive your child care referrals? |
| E-mail
Mail
|
|
Our goal is to send out referrals within two business days. You may need to check your spam or junk mail because often our emails are not filtered properly. Contact us if you do not receive an email from us within three business days. |
| * E-mail |
|
| * First
Name |
|
| * Last
Name |
|
| * Address |
|
| Apt # |
|
| * City/State/Zip |
|
| * Phone |
|
| Alternate
Phone |
|
| Family Composition |
|
| Have you served in the military? |
Yes
No |
| Are you employed? |
Yes
No |
| Is your spouse employed? |
Yes
No |
| Employer |
|
| Spouse’s Employer |
|
| If you do not have health insurance, would you be interested in being contacted to determine if you are eligible or to learn more about free or low cost public health insurance? |
Yes
No |
* Please indicate the household income range that you would fall within. If the household income falls within the low income range, parents are working, or you are under 21 years of age and attending high school, you may be eligible for financial assistance to help pay for your child care. If you would like information about child care subsidy, please contact our subsidy coordinator at (914) 761-3456 ext. 122. |
Family size 2
No Income
Below $30,260 Low Income
$30,261 to $41,608 /Title XX
$41,609 to $48,081
Above $48,082
Family size 3
No Income
Below $38,180 /Low Income
$38,181 to $48,680 /Title XX
$48,681 to $56,029
Above $56,030
Family size 4
No Income
Below $46,010 /Low Income
$46,011 to $51,863 /Title XX
$51,864 to $59,535
Above $59,536
Family size 5
No Income
Below $54,020 /Low Income
$54,021 to $60,773 /Title XX
$60,774 to $69,633
Above $69,634 |
Family size 6
No Income
Below $61,940 /Low Income
$61,941 to $69,683 /Title XX
$69,684 to $79,731
Above $79,732
Family size 7
No Income
Below $69,860 /Low Income
$69,861 to $78,593 / Title XX
$78,594 to $89,829
Above $89,830
Family size 8
No Income
Below $77,780 /Low Income
$77,781 to $87,503 / Title XX
Above $87,504 |
|
Child
1 |
|
Child's First Name
|
Boy
Girl
Expecting |
* Child's Date
of Birth
(If expecting, enter anticipated date of birth.) |
|
| * Days
Care Needed |
Drop off Time Pick up Time |
Monday through Friday
|
|
|
Sunday |
|
|
Monday |
|
|
Tuesday |
|
|
Wednesday |
|
|
Thursday |
|
|
Friday |
|
|
Saturday |
|
*When do you need the care to begin?
(Enter a specific date) |
|
* Type
of Care
(Check all that apply.) |
Child Care Center
(In a non-residential building where children are separated by age group)
Family Child Care
(In a residential building where children are in a mixed age group)
Before or After School Care
(For children 5 years old and already enrolled in Kindergarten to the age of 12 years old)
In-Home
(Your child cared for in your home)
Nursery School
(Care for 3 hours or less a day)
Camp/Summer Care
|
| If
care is needed for a school age child, provide the name of school
your child attends. |
|
| * Desired
location of care |
Close to home (If different from above, provide address.)
(You may also list towns or zip codes.)
Close to work (Please provide address if known.)
(You may also list towns or zip codes.)
Close to child’s school (Please provide address if known.)
(
You may also list towns or zip codes.)
Other (Please provide address if known.)
(
You may also list towns or zip codes.)
|
Child 2 |
|
Child's First Name
|
Boy
Girl
Expecting |
Child's Date
of Birth
(If expecting, enter anticipated date of birth.) |
|
| Days
Care Needed |
Drop off Time Pick up Time |
Monday through Friday
|
|
|
Sunday |
|
|
Monday |
|
|
Tuesday |
|
|
Wednesday |
|
|
Thursday |
|
|
Friday |
|
|
Saturday |
|
When do you need the care to begin?
(Enter a specific date) |
|
Type
of Care
(Check all that apply.) |
Child Care Center
(In a non-residential building where children are separated by age group)
Family Child Care
(In a residential building where children are in a mixed age group)
Before or After School Care
(For children 5 years old and already enrolled in Kindergarten to the age of 12 years old)
In-Home
(Your child cared for in your home)
Nursery School
(Care for 3 hours or less a day)
Camp/Summer Care
|
| If
care is needed for a school age child, provide the name of school
your child attends. |
|
| Desired
location of care |
Close to home (If different from above, provide address.)
(You may also list towns or zip codes.)
Close to work (Please provide address if known.)
(You may also list towns or zip codes.)
Close to child’s school (Please provide address if known.)
(
You may also list towns or zip codes.)
Other (Please provide address if known.)
(
You may also list towns or zip codes.) |
| Additional
Comments |
|
| The Council receives funding from NYS to provide free child care referrals to families like you. They are asking us to collect some Census/Demographic information on the families we assist. Could you please take a moment to provide the following information? You can choose not to respond. |
| I choose not to respond to these questions. |
|
| Do you speak a language other than English at home? |
Yes
No |
| What is your race? |
|
| |
Image Verification
Please enter the text from the image |
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| |
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For additional information, questions or concerns,
call to speak to one of our Resource & Referral Counselors.
914–761-3456 ext. 140
Monday – Friday
9am – 5pm
Disclaimer: The names are intended as referral options only and not recommendations. The information about the child care providers on our database is supplied by the providers themselves and has not been verified by the Council. The Council does not recommend any particular provider nor can we guarantee a provider’s capabilities or the quality of care. Therefore, inclusion on the database should not be seen as an endorsement of nor recommendation by the Council. Since selecting a provider is a subjective decision, you should visit several providers to determine which is best for your family and decide for yourself if any fulfill your needs.
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