VAC | Vermont Achievement Center | Child Care Support Services

Parent Intake Form
Caller name
Telephone		Work
Employer
Parent name
Address
City		State
Zip
E-mail
Region
Worksite location
Spouse’s name
Spouse’s employer
How did you hear of this service?
What are you looking for in a child care provider?

Subsidy Eligible (check all that apply)
A. Receives child care subsidy	Yes No
B. Receives ANFC/TANF	Yes No
C. Income eligible/App. in process	Yes No
1. SRS protective services	Yes No
2. Emergency care	Yes No
3. Job stability threatened	Yes No
4. Special needs*	Yes No
5. Difficult search	Yes No
A. Infant search	Yes No
B. Odd hours of care	Yes No
C. Minor parent	Yes No
D. Extended consumer education	Yes No
E. 3+ repeat calls	Yes No
F. Transportation	Yes No
G. Homeless	Yes No
H. 3+ children	Yes No
I. English as primary language	Yes No
6. Other (please describe)	Yes No

First Child’s name		Gender	Birthdate
Preferred setting			Special needs
Date needed			FT/PT/SAC
Days	M T W Th F S S		Hours	to

Second Child’s name		Gender	Birthdate
Preferred setting			Special needs
Date needed			FT/PT/SAC
Days	M T W Th F S S		Hours	to

Third Child’s name		Gender	Birthdate
Preferred setting			Special needs
Date needed			FT/PT/SAC
Days	M T W Th F S S		Hours	to

Fourth Child’s name		Gender	Birthdate
Preferred setting			Special needs
Date needed			FT/PT/SAC
Days	M T W Th F S S		Hours	to

Preferred fee
Preferred location
Comments (schools, transportation, etc.)
Reason needing care
Special needs
Other health needs

Referrals are recommendations only.
This is a free and confidential service.

Who to contact with a concern:

• If you have any concerns about the referral service you have received please call 1-800-649-2642.
• For concerns about a child care provider in the state of Vermont please call 1-800-540-7942.
• You can obtain complete copies of compliant policies and procedures by calling Child Care Services directly.