Intake Form

Customer Intake Form

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.
  • 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
  • 2. LOCATE has an enhanced service for children who have an IEP/IFSP for cognitive, motor, medical, or social challenges including behavior. Are you interested in that service?
  • 4. Do you need care for only the child(ren) who has the IEP/IFSP?
    *If you are looking for care for more than three children, please call us at 877.261.0060
  • MM slash DD slash YYYY
  • 10. Are you homeless?
  • 14. Best way to reach you during the day:
  • 18. Near what address do you want care?
  • 22. Should we contact you in your native language?
  • 23. To evaluate our service, we do follow up calls to our clients. May we call you?
  • 25. What is your relationship to the child?
  • 26. Are you Active Duty Military?
  • 27. If yes, what branch of the Military?
  • 32. Single or Dual Parent Household?
  • 36. Have you applied for TCA but have not yet started to receive benefits?
  • 37. Does your child receive Medical Assistance?
  • 38. Does your child receive Supplemental Security Income (SSI)?
  • 39. Is there health/medical insurance to cover your child or children under the age of 19?
  • Family Size of 2 the Income Limit is $41,527; Family Size of 3 the Income Limit is $52,245; Family Size of 4 the Income Limit is $62,964; Family Size of 5 the Income Limit is $73,682; Family Size of 6 the Income Limit is $84,400; Family Size of 7 the Income Limit is $95,118; Family Size of 8 the Income Limit is $107,943
  • 40. Do you think you may be eligible?
  • Family Size of 1 the Income Limit is $21,775; Family Size of 2 the Income Limit is $29,471; Family Size of 3 the Income Limit is $37,167; Family Size of 4 the Income Limit is $44,863; Family Size of 5 the Income Limit is $52,559; Family Size of 6 the Income Limit is $60,255; Family Size of 7 the Income Limit is $67,951; Family Size of 8 the Income Limit is $75,647;
  • 41. Do you think you may be eligible?
  • 42. Do you receive the Child Care Scholarship (Previously Child Care Subsidy)?
  • 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;
  • 43. Do you think you may be eligible?
  • 44. Do you need information on Child Support Enforcement?
  • 45. Your family may be eligible for the Earned Income Tax Credit if you ere raising one child and earned less than $39,131 in 2017 (less than $44,651 married filing jointly or if you were raising two or more children and earned less than $44,454 (less than $49,974, married, filing jointly.
  • 48. What type of Transportation will you be using?
  • First Name of Child
  • 57. Escort? Child #1:
  • :
  • :
  • 60. Are you looking for care for more than one child without an IEP or IFSP?
  • First Name of Child
  • 62. Length of Care Needed, Child #2
  • 63. Days of the week Child #2
  • 64. Hours Child #2
  • 67. Escort? Child #2:
  • :
  • :
  • First Name of Child
  • 71. Length of Care Needed, Child #3
  • 72. Days of the week Child #3
  • 73. Hours Child #3
  • 76. Escort? Child #3:
  • :
  • :

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