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Family Intake Form for Inclusion

Please identify your role:

Parent First Name

Parent Last Name

Gender

Address 1

City

County *

Zip

Phone

Email *

Child's Age

Do you currently have childcare?

What is the reason for seeking care? Please check all that apply.

Current care closing
Current care is no longer working for us
Current needs changed
Employment
Exploring options
Relocating
School

Please identify all program options that you are interested in looking for below:

Accepts childcare subsidies
Close to public transit
Military Discount
Sliding fee
Early childhood 0-3
Preschool Age 3-6
School Age 5-12

Does the child have an identified delay or disability?

Please identify all areas of need for the child

Medical
Physical
Social/Emotional
Pre-Academic/Academic Learning
Speech/Language
Other

Please check all that apply and identify all general supports needed due to disabilities, impairments, or developmental delays that are relevant to the child.

Administer medications
On site nurse
Special diets
Transportation
Walker access
Wheelchair access

Please check all that apply and identify specific care you are searching for.

24 hours
After school
Before school
Drop-in/hourly
Evenings
Extended hours
Full-time
Infant part-time
Open on holidays
Overnight
Part-time
Rotating
Temporary

Is the family interested in receiving a list of registered providers?

Please check all that apply and identify the schedule you are looking for.

Full year
School year
Summer only

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Password

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Email

Please contact us at (314) 531-1412 or trainings@united4children.org

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