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CCRR Web Intake Form

* Required Fields
Section One - Parent Information
First Name: *  
Last Name: *  
Address: *  
City: *  
State: *
Zip: *  
Email Address: *  
Phone:  
Section Two - Child(renīs) Information
*Note: Please fully complete this section for all children before moving to Section 3. Thank You.
Child 1
Child´s First Name: *  
Child´s Last Name: *  
Child’s Date of Birth: *  
Hours of Daycare (i.e. 7 am to 6 pm): *  
Days of Child Care: *
S
M
T
W
Th
F
S
Zip Code for Child Care 1st Choice: *  
Zip Code for Child Care 2nd Choice: *  
Zip Code for Child Care 3rd Choice: *  
Type of Child Care: *
Child Care Centers
Family Child Care Homes
Large Family Child Care Homes
School-Age Programs
Voluntary Prekindergarten
Summer Voluntary Prekindergarten
Head Start
Playgroups
Nanny or Babysitting Agencies
Summer School-Age Programs
School-Age child attends what school?: *  
Does child need before school care?: *
Yes
No
Does child need after school care?: *
Yes
No
Does child need transportation to school?: *
Yes
No
Does child need transportation from school?: *
Yes
No
Child 2
Childīs First Name:  
Childīs Last Name:  
Child’s Date of Birth:  
Hours of Daycare (i.e. 7 am to 6 pm):  
Days of Child Care:
S
M
T
W
Th
F
S
Zip Code for Child Care 1st Choice:  
Zip Code for Child Care 2nd Choice:  
Zip Code for Child Care 3rd Choice:  
School-Age child attends what school?:  
Type of Child Care:
Child Care Centers
Family Child Care Homes
Large Family Child Care Homes
School-Age Programs
Voluntary Prekindergarten
Summer Voluntary Prekindergarten
Head Start
Playgroups
Nanny or Babysitting Agencies
Summer School-Age Programs
School-Age child attends what school?:  
Does child need before school care?:
Yes
No
Does child need after school care?:
Yes
No
Does child need transportation to school?:
Yes
No
Does child need transportation from school?:
Yes
No
Child 3
Childīs First Name:  
Childīs Last Name:  
Child’s Date of Birth:  
Hours of Daycare (i.e. 7 am to 6 pm):  
Days of Child Care:
S
M
T
W
Th
F
S
Zip Code for Child Care 1st Choice:  
Zip Code for Child Care 2nd Choice:  
Zip Code for Child Care 3rd Choice:  
Type of Child Care:
Child Care Centers
Family Child Care Homes
Large Family Child Care Homes
School-Age Programs
Voluntary Prekindergarten
Summer Voluntary Prekindergarten
Head Start
Playgroups
Nanny or Babysitting Agencies
Summer School-Age Programs
School-Age child attends what school?:  
Does child need before school care?:
Yes
No
Does child need after school care?:
Yes
No
Does child need transportation to school?:
Yes
No
Does child need transportation from school?:
Yes
No
Child 4
Childīs First Name:  
Childīs Last Name:  
Child’s Date of Birth:  
Hours of Daycare (i.e. 7 am to 6 pm):  
Days of Child Care:
S
M
T
W
Th
F
S
Zip Code for Child Care 1st Choice:  
Zip Code for Child Care 2nd Choice:  
Zip Code for Child Care 3rd Choice:  
Type of Child Care:
Child Care Centers
Family Child Care Homes
Large Family Child Care Homes
School-Age Programs
Voluntary Prekindergarten
Summer Voluntary Prekindergarten
Head Start
Playgroups
Nanny or Babysitting Agencies
Summer School-Age Programs
School-Age child attends what school?:  
Does child need before school care?:
Yes
No
Does child need after school care?:
Yes
No
Does child need transportation to school?:
Yes
No
Does child need transportation from school?:
Yes
No
Child 5
Childīs First Name:  
Childīs Last Name:  
Child’s Date of Birth:  
Hours of Daycare (i.e. 7 am to 6 pm):  
Days of Child Care:
S
M
T
W
Th
F
S
Zip Code for Child Care 1st Choice:  
Zip Code for Child Care 2nd Choice:  
Zip Code for Child Care 3rd Choice:  
Type of Child Care:
Child Care Centers
Family Child Care Homes
Large Family Child Care Homes
School-Age Programs
Voluntary Prekindergarten
Summer Voluntary Prekindergarten
Head Start
Playgroups
Nanny or Babysitting Agencies
Summer School-Age Programs
School-Age child attends what school?:  
Does child need before school care?:
Yes
No
Does child need after school care?:
Yes
No
Does child need transportation to school?:
Yes
No
Does child need transportation from school?:
Yes
No
Child 6
Childīs First Name:  
Childīs Last Name:  
Child’s Date of Birth:  
Hours of Daycare (i.e. 7 am to 6 pm):  
Days of Child Care:
S
M
T
W
Th
F
S
Zip Code for Child Care 1st Choice:  
Zip Code for Child Care 2nd Choice:  
Zip Code for Child Care 3rd Choice:  
Type of Child Care:
Child Care Centers
Family Child Care Homes
Large Family Child Care Homes
School-Age Programs
Voluntary Prekindergarten
Summer Voluntary Prekindergarten
Head Start
Playgroups
Nanny or Babysitting Agencies
Summer School-Age Programs
School-Age child attends what school?:  
Does child need before school care?:
Yes
No
Does child need after school care?:
Yes
No
Does child need transportation to school?:
Yes
No
Does child need transportation from school?:
Yes
No
Section Three - Statistical Information
Household (Choose one): *
Under 17 and living on own
More than two adults
One Adult
Refused
Two Adults
Problem Finding Care (Choose one): *
Affordability
Care Ending
Program Curriculum
Location or Transportation
None
No Opening
Quality
Schedule
Reason for Care (Choose one): *
Client asked to leave program
Cost too high
End of Leave of Absence
Employed
Other/Unknown
Job Seeking
Parent/Child needs
Unhappy with quality
Refused to Answer
Relocation
Training/Education
Relationship (Choose one): *
Foster Parent
Legal Custodian
Other
Parent/Step-Parent
Relative
Refused
Teen Parent
Comments about your family’s needs in child care:
Early Learning Coalition of Hillsborough County
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Did You Know?

Every $1 invested in high quality early childhood education programs returns between $5.98 and $12.90. These returns include higher earnings (and therefore higher tax revenues), higher levels of schooling. fewer arrests (and therefore lower criminal justice system expenditures), and less welfare receipt. These findings have been replicated across multiple early education programs, and the expert consensus is that investments in early childhood education yields enormous returns to society.

Search:
ELCHC Calendar
Early Education News

With Our Future on the Line, the Time to Invest in Kids is Now
Huffington Post (4/11/12)
The State of Preschool: State Preschool Yearbook, a new report from Rutgers University's National Institute for Early Education Research, relased this week reveals that total spending on early childhood education by all 50 states and the....

Florida Leads in pre-K access, but quality lags
Tbo.com (4/10/12)
A review finds that all Florida pre-kindergarten programs should require teachers to have a bachelor's degree.

Making the case for early ed, Art Rolnick has had 'enormous impact'
MinnPost.com (4/16/12)
Invest the same sums in early childhood education, Rolnick insists, and the returns will be far greater. By linking the two issues, Rolnick has locked horns with some staunch allies inhis education campaign....

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