4C Child Care Unlimited - Child Care Referral Request

    Hours of Operation
    M, T, Th, F - 8:30-5:00
    W - 8:30-6:00

    1509 1/2 E. Court Street
    Flint, MI 48503
    Phone: 810-232-0145
    Fax: 810-232-6261

Child Care Referral Request

* Required Field

* Name:

* Street:

* City:

State:

Michigan

* Zip:

* County:

* Primary Phone:

Home Phone Cell Phone Pager

* Best time to call:

* Fax No:

* E-mail Address:

* Your employer/school:

* Employer/school of other parent in home:

What areas would you like searched? Please enter nearest intersection; i.e., I-69 X S. Grand Traverse:

* Near home:

* Near work

* Near school:

* What is your family size?:

* Does your family receive assistance from any of these FIA programs? (Check all that apply)

Temporary Assistance to Needy Families
Child Day Care Subsidy
Foster Care
Medicaid or Food Stamps

CHILD/CHILDREN INFORMATION
	First Name	Date of Birth	Date care to Begin	Relationship to Child	Potty Trained?
Child No. 1
Child No. 2
Child No. 3
Child No. 4

* Which days will care be required (please check all that apply)

Monday through Friday All seven days
OR
Mon Tue Wed Thur Fri Sat Sun

* Earliest expected drop-off time

* Latest expected pick-up time

* Type of Schedule

* Type of care wanted (more than one choice may be selected):

Center
Family Child Care Home (Up to 6 children)
Group Child Care Home (Up to 12 children)
Pre-school
Before and After School Only

* Special Program:

Montessori
Religious
Co-op
Before and After Kindergarten
Free Pre-school/Head Start
Church or Synagogue

* What schools, if any, do the children attend?

* Will your children need transportation if available?:

* Family Income:

* Child Health:

Health Plus
Medicaid
Private Insurance
Send MI Child Application
Child Not Insured

* Additional information or comments:

* Are there any special care needs that would require a provider to have a specific training for disabilities? (Please indicate yes or no)

If yes, please explain:

* How did you learn about 4C's referral service? Please select most appropriate:

* Why do you need childcare? Please check all that apply:

Employment
Return from leave of absence
Job schedule change
Child has special needs
Training
Extended work hours
Child needs
Dissatisfied with current caregiver
Relocation
Job travel
Parent needs
No provider

CHILD CARE REFERRAL DISCLAIMER

4C Child Care Unlimited does not license, endorse or recommend any one particular child care provider. Most of the information accumulated about a child care provider comes directly from the provider and is for informational purposes only. 4C Child Care Unlimited can verify the provider is either licensed or regulated by the State of Michigan. Some school-based programs are exempt from licensing rules, but parents may contact the school for other information. 4C Child Care Unlimited strongly urges parents to contact, screen and visit providers to choose someone who best meets their needs.

CHILD CARE RESOURCE AND REFERRAL CONFIDENTIALITY POLICY

It is the policy of 4C Child Care Unlimited that employees, board members and volunteers may not disclose, divulge or make accessible confidential information belonging to, or obtained through their affiliation with 4C Child Care Unlimited to any person, including relatives, friends and business and professional associates, other than to persons who have a legitimate need for such information and to whom 4C Child Care Unlimited has authorized disclosure. 4C Child Care Unlimited shall use confidential information solely for the purpose of performing services for clients who participate in programs affiliated with 4C Child Care Unlimited.

CONSUMER/PARENT COMPLAINT POLICY:
4C RESOURCE & REFERRAL SERVICES

4C Child Care Unlimited is determined to provide quality child care resource and referral services that parents expect and rely on. Consumer feedback is a valuable tool used by 4C Child Care Unlimited to improve the quality of our child resource and referral services. Parents requesting child care referral services from 4C Child Care Unlimited are encouraged to provide feedback and suggestions on the services they receive. Parents may contact the Executive Director of 4C Child Care Unlimited at 810 232–0145 or 1 800 527-2182, ext. 15.