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spacer Please choose the form you would like to complete -
dotChild Care Request Form (Blue Form)
dotChild Care Feedback Form (Green Form)



Child Care Request Form

If you would like assistance locating child care, please fill out this form or contact us at 1-580-234-3552 or 1-800-401-3463

Please note that the fields marked red are required to fully process your request.

Full Name:

Address:

Address Line 2:

City:

State:
Oklahoma

Zip:

Daytime Phone (with area code):

Evening Phone (with area code):

Email Address:

Relationship to the child(ren) for whom you need care:

Work Address:

Work Phone Number:

Fax Number(home or work):

Nearest Work Intersection:

Year schedule:
Full Year
School Year
Summer

Does your child(ren) have any special needs?
none  infant monitor  ADHD (hyperactivity)
hearing impaired  vision impaired  physically disabled
wheelchair accessible  diabetes  immune deficiency
learning disabled  mentally disabled  emotionally disabled
seizures  tube feeding  asthma
other    

Does your child need transportation?
None
To and from school
To school
From school
Both to and from school

What other criteria are you looking for in a child care provider?
non-smoking environment
no pets
no preference

Do you have any type of Subsidy?
None
DHS
Sliding Scale
SSI
Indian Contract

How did you find out about us?
search engine
personal referral (e.g. friend, co-worker, RR agency)
commercial
Other

If you need child care for more than two children, please enter the information below:

How do you want the referral specialist to get this information back to you?
Fax
Email
Phone
Mail


1st Child's Information

Name of Child:

Birthday:

Age:

Date Care Needed:

Preferred Type of Care (select all that apply):
Child Care Center
Family Child Care Home
Nursery/Preschool
School Age Care
Montessori
Drop-In / Playtime
Camp
Before & After School
Summer Camp
Other

Special Schedule:
Drop in
Hourly
temp/emergency
Sick Care
24 hour

Where do you want this care located?
Near work
Close to home
Between work and home
Near Child's School
no preference
Other


Hours Needed:

Days:
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Additional requirements/special needs:


2nd Child's Information

Name of Child:

Birthday:

Age:

Date Care Needed:

Preferred Type of Care (select all that apply):
Child Care Center
Family Child Care Home
Nursery/Preschool
School Age Care
Montessori
Drop-In / Playtime
Camp
Before & After School
Summer Camp
Other

Special Schedule:
Drop in
Hourly
temp/emergency
Sick Care
24 hour

Where do you want this care located?
Near work
Close to home
Between work and home
Near Child's School
no preference
Other


Hours Needed:

Days:
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Additional requirements/ special needs:


Please complete the following Census Bureau questions:
Are you?
 I choose not to answer
 Spanish/Hispanic/Latino
 Mexican/Mexican American, Chicano
 Puerto Rican
 Cuban
 Other - please specify 

What is your Race?
 I choose not to answer
 White
 African American
 American Indian/Alaskan
 Asian Indian
 Native Hawaiian
 Chinese
 Filipino
 Japanese
 Vietnamese
 Other Asian
 Guamanian or Chamorro
 Samoan
 Other Pacific Islander
 Other

Do you speak a language other than English at home?
 No      Yes - please specify 


Additional Information About You:
Your Age
 Under 20 years
 20-29 years
 30-39 Years
 40-49 years
 50 or over


Relationship to Children listed above:
 Father
 Mother
 Grandparent
 Guardian
 Relative
 Foster Parent
 Other


Current Employment Status:
 Employed
 Seeking Employment
 At Home
 Student
 TANF


Family Income (Yearly):
 Up to $28,000
 Greater than $28,000
 I choose not to answer


Family Size:


Number of Adults in Home:



Thank you for taking the time to complete this form.
Please enter the code shown below and then click the 'Submit Request Form' to send us your information.


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Child Care Feedback Form

Please take a few minutes to fill out this form.
Your feedback will help us create a web site that will better suit your needs.

Describe Yourself:
Parent
Center Teacher
Center Director
Family Child Care Provider
CCR&R Professional
Other

Did you find the information you were looking for on our web site?
Yes
No

If not, what additional information would you have liked to have seen?

How satisfied were you with our web site?
Very Satisfied
Somewhat Satisfied
Not Satisfied

What suggestions do you have for improving our web site?

Would you recommend our web site to others?
Yes
No

Overall Comments:



Thank you for taking the time to complete this form.
Please enter the code shown below and then click the 'Submit Feedback Form' to send us your information.


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