Family Resource Support - Child Care Resource Center of Baltimore County

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Customer Intake Form

Welcome to LOCATE: Child Care's customer intake form. Please complete the form to let us know your child care needs. We will search for providers who meet your needs and send you a list of up to six providers. If at anytime you would like another list, please call us at 877.261.0060 and we can send you one quickly. If you are a full-time employee or student of Johns Hopkins University or Health System, please go to the following link: https://www.surveymonkey.com/r/T52GK6M LOCATE has an enhanced service for children who have Special Needs and an Individualized Educational Plan (IEP) or an Individualized Family Service Plan (IFSP ) If you would like to use this service, please go to https://www.surveymonkey.com/r/GD2C6T2

In order to receive referrals you must accept the disclaimer above. * Required
- I accept the disclaimer above.
DISCLAIMER: All providers listed in LOCATE: Child Care are regulated or approved by the Maryland State Department of Education or certified by the Maryland Department of Health and Mental Hygiene. When LOCATE identifies child care program options for parents, it means only that the programs identified are regulated by the appropriate agency and have met the criteria that agency sets forth. The responsibility for providing LOCATE with accurate listings of regulated providers/programs rests with the appropriate agencies. Responsibility for selecting and employing a child care provider rests with each parent. LOCATE: Child Care cannot guarantee the quality of providers in its files and urges parents to carefully interview and check references before leaving a child in care. A referral from LOCATE does not constitute a recommendation as to the quality of care.
Today's Date
MM slash DD slash YYYY
First Name * Required
7. Middle Initial
Last Name * Required
Address * Required
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email Address
Primary Phone Number
Is your primary phone a cell phone?
- Yes
- No
Secondary Phone Number
Is your secondary phone a cell phone?
- Yes
- No
Best way to reach you during the day:
- Primary Phone Number
- Secondary Phone Number
- Email only
What county do you live in? * Required
- Baltimore County
- Cecil
- Harford
If your county is not listed please visit https://www.marylandfamilynetwork.org/for-parents/locate-child-care
What county do you want child care in? * Required
- Baltimore County
- Cecil
- Harford
Where would you like child care?
- Near my Residence (Address above)
- Near my Employment
- Near my child's School
- Near Residence, Employment or School
- On Route to Employment or School
If you want care near an address other than your residence address, please enter that address here.
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Reason for Needing Child Care * Required
- Parent's Job
- Parent Attending School
- Parent in Job Training Program
- Parent Looking for Work
- Parent Respite
- Child's Socialization
- Child's Education
- Current Care Closing
- Dissatisfied with Current Care
- Terminated or at Risk for Termination do to Behavioral Challenges
What is your native Language?
Should we contact you in your native language?
- Yes
- No
To evaluate our service, we do follow up calls to our clients. May we call you?
- Yes
- No
What is your relationship to the child?
- Parent
- Grandparent
- Other Relative
- Foster Parent
- Social Worker
How did you hear about LOCATE: Child Care? * Required
- Child Care Resource Center (Abilities Network)
- Child Care Scholarship
- Child Care Aware
- Child Care Provider
- Coworker
- Doctor's Office
- Department of Social Services
- Event
- Friend/Family
- Google or other web search
- Hospital/NICU
- Infants and Toddlers Program
- Maryland EXCELS
- Maryland Family Network
- Office of Child Care
- Previous LOCATE user
- Printed Advertisment
- Radio
- School
- Social Media
- Social Worker other than DSS
- WIC
How would you like to receive referrals? * Required
- Email
- Postal Mail
- Over the phone
How many people are in your household?
Household Structure?
- Single Parent
- Dual Parent
- Multi Family
How many children need child care? * Required
Does your family receive ? (Check all that apply)
- Temporary Cash Assistance (TCA)
- Applied for TCA (has not received yet)
- Food Stamps (SNAP)
- Maryland Children's Health Program
- Supplemental Security Income
- Child Care Scholarship
If you are not currently receiving the Child Care Subsidy, you may be eligible if your income meets the following income guidelines:

Family Size of 2 the Income Limit is $61,222; Family Size of 3 the Income Limit is $75,627; Family Size of 4 the Income Limit is $90,033; Family Size of 5 the Income Limit is $104,438; Family Size of 6 the Income Limit is $118,843; Family Size of 7 the Income Limit is $121,544; Family Size of 8 the Income Limit is $124,245; Family Size of 9 the Income Limit is $126,946 Family Size of 10 the Income Limit is $1129,647;
Do you think you may be eligible?
- Currently Receiving
- Yes - Eligible
- No - Above income eligibility guidelines
- On waiting list
- Prefer not to give income information
Preferred zip codes for care?
Zip Code 1
Zip Code 2
Zip Code 3
Zip Code 4
48. What type of Transportation will you be using?
- Car
- Walk
- Public Bus
- Light Rail
- Subway
49. What is your current child care arrangement? * Required
- Licensed family child care provider
- License Group Program
- Relative (in relative's home)
- Relative (in your home)
- In-home (in parent's home)
- Babysitter (non-relative to child in babysitter's own home)
- Currently not using any child care
50. Do you know of any current providers?
Please enter information here only for the children without an IEP or IFSP. At the end of the document, you will have the option to go to the form for our Special Needs Service.
51. Children for whom you need care: Child #1 * Required

First Name of Child
Gender * Required
Date of Birth * Required
How much are you able to pay per week for Child #1? * Required
Care Need in (Days) * Required
52. Length of Care Needed, Child # 1 * Required
- Full Time
- Part Time
- Temporary
- Back up
53. Days of the week Child # 1 * Required
- Monday-Friday
- Weekday + Weekend
- Weekend only
- Flex
- Part Week
54. Hours Child #1 * Required
- Daytime
- Evening
- Early
- Overnight
- Flexible
- Before School
- After School
- Before and After School
- Before and After Middle School
- Before and After Preschool
55. Type of Care Child #1 Select all that apply: * Required
- Child Care Center
- Licensed Family Child Care Provider
- Head Start (Income Requirements) *
- Early Head Start (Income Requirements *
- Public PreK (Income Requirements)*
- Private PreK
- Private Kindergarten
- Part-time Preschool
- CO-OP (Cooperative preschool, parents participate)
- CAMP
- Summer Program
56. Name of Elementary School Child #1:
57. Escort? Child #1:
- Yes
- No
58. Drop off time Child #1:

: Hours

Minutes

AM/PM AM/PM
59. Pick up time Child #1:

: Hours

Minutes

AM/PM AM/PM
60. Are you looking for care for more than one child without an IEP or IFSP?
- Yes
- No
61. Children for whom you need care: Child #2

First Name of Child
Gender
Date of Birth
How much are you able to pay per week for Child#2?
Care need in (days)
62. Length of Care Needed, Child #2
- Full Time
- Part Time
- Temporary
- Back up
63. Days of the week Child #2
- Monday-Friday
- Weekday + Weekend
- Weekend only
- Flex
- Part Week
64. Hours Child #2
- Daytime
- Evening
- Early
- Overnight
- Flexible
- Before School
- After School
- Before and After School
- Before and After Middle School
- Before and After Preschool
65. Type of Care Child #2 Select all that apply:
- Child Care Center
- Licensed Family Child Care Provider
- Head Start (Income Requirements) *
- Early Head Start (Income Requirements *
- Public PreK (Income Requirements)*
- Private PreK
- Private Kindergarten
- Part-time Preschool
- CO-OP (Cooperative preschool, parents participate)
- CAMP
- Summer Program
66. Name of School Child #2:
67. Escort? Child #2:
- Yes
- No
68. Drop off time Child #2:

: Hours

Minutes

AM/PM AM/PM
69. Pick up time Child #2:

: Hours

Minutes

AM/PM AM/PM
70. Children for whom you need care: Child #3

First Name of Child
Gender
Date of Birth
How much are you able to pay per week for Child #3?
Care need in (days)
71. Length of Care Needed, Child #3
- Full Time
- Part Time
- Temporary
- Back up
72. Days of the week Child #3
- Monday-Friday
- Weekday + Weekend
- Weekend only
- Flex
- Part Week
73. Hours Child #3
- Daytime
- Evening
- Early
- Overnight
- Flexible
- Before School
- After School
- Before and After School
- Before and After Middle School
- Before and After Preschool
74. Type of Care Child #3 Select all that apply:
- Child Care Center
- Licensed Family Child Care Provider
- Head Start (Income Requirements) *
- Early Head Start (Income Requirements *
- Public PreK (Income Requirements)*
- Private PreK
- Private Kindergarten
- Part-time Preschool
- CO-OP (Cooperative preschool, parents participate)
- CAMP
- Summer Program
75. Name of School Child #3:
76. Escort? Child #3:
- Yes
- No
77. Drop off time Child #3:

: Hours

Minutes

AM/PM AM/PM
78. Pick up time Child #3:

: Hours

Minutes

AM/PM AM/PM
79. Special Requirements (Check all that apply)
- Non-smoking home
- Smoke-free during the day (Smoking occurs only during non child care hours)
- Fenced Yard
- No pool
- Assist in toilet training
- No dogs
- No cats
- Other
80. Other information you would like us to know:
81. Comments

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