Child Care Referral Request Form
* You must complete the bolded fields in order to receive a referral.
I. General Information
Parent/Guardian's Name:
Street Address:
City, State, Zip Code:
Daytime Phone:
Email Address:
Employer of Parent/Guardian:
2nd Employer:
Birthdate(s) of Children (or due date)
II. Search Criteria
Cities to Search: (enter 2 cities maximum)
You may submit additional referral requests if you require a search of more than 2 cities.
Type of Care:
Start Date of Child Care:
Days Care is Needed: (Select all of the days for which you'll need care)
(include drop off and pick up time: Example - 8a.m. - 6p.m.)
Time Care is Needed:
Type of Schedule:
Special Program: (optional)
Other Care Options: (optional)
Bi-Lingual Child Care Select Language:
Child Care provider for special needs:
III. Subsidy
Is the Department of Human Services (DHS) helping to pay for care?
DHS offers a program to assist low to moderate income families pay for child care. Eligibility is based on family size and yearly income. To qualify, the gross yearly income must be below the amounts listed in this chart.
FAMILY SIZE
| YEARLY INCOME
| 2
| $19,200
| 3
| $23,900
| 4
| $28,400
| 5
| $32,950
| 6
| $37,500
| 7
| $42,000
|
Would you like a Department of Human Services
(DHS) application mailed to you?
IV. Reason For Care:
What is your reason for needing child care?
How were you referred to us?
How would you like us to send your referral?
The following is optional and is collected for statistical information purposes only.
What is your age?
What is your employment status?
If you speak another language in the home,
Please indicate which language?
What is your family size?
What is your relationship to the Child/Children?
What is your Ethnic Background/Race?
Additional Comments:
If you do not receive your referral list within two business days please contact us at (248) 333-9545
If you would like to be added to our parent distribution list
please enter your email address.
Confidentiality Policy
It is the policy if the Oakland County Child Care Council to keep all personal information shared by clients confidential. All information gathered is for statistical purposes, and no information is shared with outside parties. Personal information is defined as name, address, phone number, or fax number and email address.
Resource and Referral Complaint Policy
The Oakland County Child Care Council strives to provide the best resource and referral service possible. We are committed to resolving service complaints to the best of our ability, as well as guiding clients through the state Licensing Complaint process should a concern about a child care provider arise.
If you have a concern or complaint about the health, safety or quality of a child care provider, we offer the following information:
1. You may call Child and Adult Day Care Licensing at (866) 856-0126 or online at www.mi.gov/dhs. Under "How do I" scroll to "File a licensing complaint."
2. You do not have to give any identifying information, the complaint will be investigated even if it is filed anonymously. If identifying information is provided the investigator may call for clarification or more information.
3. An Investigation Report will be available online or through a Freedom of Information Act(FOIA) request within 90 days.
4. FOIA Request may be completed online at www.mi.gov/dhs by fax (517) 335-6121 or in writing to the Department of Human Services Office of Child and Adult Day Care Licensing 7109 W. Saginaw, PO Box 30650, Lansing, MI 48909
5. FOIA Requests are not confidential and may require a minimal fee.
6. The Oakland County Child Care Council does not investigate or follow up on ANY provider complaints.
If you have a concern or complaint with the quality of service received from one of our Resource and Referral Counselors, you may contact Executive Director via phone, fax or email. Executive Director verifies information received and documents your concerns in writing. The Executive Director will work with you and the staff to resolve any issues. Written documentation is kept on file.
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