Child Care Intake

Child Care Intake
Today's Date*

MonthDayYear
Date
Name*

First NameLast Name
Gender?*

FemaleMaleTrans-FemaleTrans-MaleGender Non-ConformingDeclined
Race?*

Black / African AmericanAsianNative American or Alaska NativeNative Hawaiian or Other Pacific IslanderWhite / CaucasianDeclined
Ethnicity?*

Hispanic / LatinoNon-Hispanic / Non-LatinoDeclined
Parent/Guardian Date of Birth*

MonthDayYear
Date
Phone Number*

Area CodePhone Number
Can we leave a voicemail?*

YesNo
Can we text you?*

YesNo
Do you have an email?*

YesNo
Do you have an email?*

YesNo
Email
If no email, clarify other options

Mail listing to home addressPick up list at the Helpline Center
Email
example@example.com
Do you have an email?*
Yes or No (I can only email or mail the listing)
Address*

Street Address

Street Address Line 2

CityCounty

Zip Code
Are you Receiving Child Care Assistance?*

YesNoApplication PendingPlanning on Applying
Child 1 Name*
Child 1: Date of Birth/Due Date*
Gender?*

FemaleMaleTrans-FemaleTrans-MaleGender Non-ConformingDeclined
Child 2 Name
Child 2: Date of Birth/Due Date
Gender?

FemaleMaleTrans-FemaleTrans-MaleGender Non-ConformingDeclined
Child 3 Name
Child 3: Date of Birth/Due Date
Gender?

FemaleMaleTrans-FemaleTrans-MaleGender Non-ConformingDeclined
Child 4 Name
Child 4: Date of Birth/Due Date
Gender?

FemaleMaleTrans-FemaleTrans-MaleGender Non-ConformingDeclined
Child 5 Name
Child 5: Date of Birth/Due Date
Gender?

FemaleMaleTrans-FemaleTrans-MaleGender Non-ConformingDeclined
Child 6 Name
Child 6: Date of Birth/Due Date
Gender?

FemaleMaleTrans-FemaleTrans-MaleGender Non-ConformingDeclined
Days of Care Needed (ex. Monday - Friday)*
Hours of Care Needed (ex. 8:00am to 5:00pm)*
Preference for child care setting (select all that apply)*

In-Home DaycareDaycare CenterPreschool Program (3-5 years old)
What type of care are you looking for? (select all that apply)*

Full TimePart TimeAfter- SchoolBefore-SchoolDrop-inSummer Only
Are you interested in learning more about financial assistance for preschool? (Only for the Sioux Falls area)

YesNo
Elementary School Child(ren) Attend:
Have you used a provider in the past year?*

YesNo
Which provider(s) have you used? Reason for change(s)?
Other Notes:
You understand the collection and use of all your personal information is protected by strict standards of confidentiality as outlined in writing in the Helpline Center Network of Care Policies and Procedures and that this agency cannot provide specific legal advice regarding your rights on any of this information. You also understand that your personal information will only be disclosed in accordance with applicable South Dakota laws.
Do you consent?*

I agreeI disagree
Staff who filled out this form*

First NameLast Name
Should be Empty: