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Services
Family Life
CKF Health Insurance Assistance
CAP Early Learning Center
Early Head Start
Head Start
Next Level Youth Mentoring
WIC – Women, Infants, and Children
Community Resource Directories
Parental Guide to Youth Drug Prevention
Domestic Violence Shelters and Assistance
Resources for Veterans, Disabled, and Mental Illness
Housing
Properties
Rental Information
Rental Application
Income Certification Questionnaire
View all Properties
Section 8 Housing Choice Voucher Program
Lead Paint Testing
Weatherization
Energy Assistance
Financial Planning
Small Business Loans
Homeownership Education and Counseling Program
Elder Adults
News
About
Annual Reports, Audit Results, 990 Forms, and RFPs
Board of Directors
Customer Satisfaction Survey and Community Needs Assessment
Employment Opportunities
Joan E. Cline Memorial Scholarship
Make a Donation
FAQs
Locations
Contact
Members Area
Home
Services
Family Life
CKF Health Insurance Assistance
CAP Early Learning Center
Early Head Start
Head Start
Next Level Youth Mentoring
WIC – Women, Infants, and Children
Community Resource Directories
Parental Guide to Youth Drug Prevention
Domestic Violence Shelters and Assistance
Resources for Veterans, Disabled, and Mental Illness
Housing
Properties
Rental Information
Rental Application
Income Certification Questionnaire
View all Properties
Section 8 Housing Choice Voucher Program
Lead Paint Testing
Weatherization
Energy Assistance
Financial Planning
Small Business Loans
Homeownership Education and Counseling Program
Elder Adults
News
About
Annual Reports, Audit Results, 990 Forms, and RFPs
Board of Directors
Customer Satisfaction Survey and Community Needs Assessment
Employment Opportunities
Joan E. Cline Memorial Scholarship
Make a Donation
FAQs
Locations
Contact
Members Area
Home
Services
Family Life
CKF Health Insurance Assistance
CAP Early Learning Center
Early Head Start
Head Start
Next Level Youth Mentoring
WIC – Women, Infants, and Children
Community Resource Directories
Parental Guide to Youth Drug Prevention
Domestic Violence Shelters and Assistance
Resources for Veterans, Disabled, and Mental Illness
Housing
Properties
Rental Information
Rental Application
Income Certification Questionnaire
View all Properties
Section 8 Housing Choice Voucher Program
Lead Paint Testing
Weatherization
Energy Assistance
Financial Planning
Small Business Loans
Homeownership Education and Counseling Program
Elder Adults
News
About
Annual Reports, Audit Results, 990 Forms, and RFPs
Board of Directors
Customer Satisfaction Survey and Community Needs Assessment
Employment Opportunities
Joan E. Cline Memorial Scholarship
Make a Donation
FAQs
Locations
Contact
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Application
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Application
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Child's Name
First
Last
Current EHS/HS Student
Yes
No
Birth Date
MM slash DD slash YYYY
Nickname
Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Your Name
First
Last
Your Email
(Required)
Child lives with:
Guardian #1 Name
First
Last
Guardian #1 Contact Information
Phone (Home)
Phone (Work)
Phone (Cell)
Place of Work
Relationship
Guardian #2 Name
First
Last
Guardian #2 Contact Information
Phone (Home)
Phone (Work)
Phone (Cell)
Place of Work
Relationship
Emergency Contact Person #1
Name
Phone Number
Add
Remove
Emergency Contact Person #2
Name
Phone Number
Do you have a backup care provider? If yes, who?
Beginning date needing care
MM slash DD slash YYYY
Hours Needed
Monday
Tuesday
Wednesday
Thursday
Friday
Add
Remove
Hours Needed
Times you plan to drop your child off
Times you plan to pick your child up
Does your child have any speech, hearing or visual problems? If so, please explain:
Would there be any restrictions with play or activities?
Has your child ever been in child care before?
Yes
No
What type (center, childcare home, family, etc.
Was it a positive experience?
Yes
No
Why are you looking for child care?
How does your child feel about daycare and being left by his/her family member?
Are there any recent traumatic situations the child has been exposed to such as a death in the family, divorce, new sibling etc?
What is your normal method of discipline?
What is your child's temperament? Are they easy going, hard to please, demanding, aggressive, etc.?
Are there any food restrictions? (a doctor’s note may be required)
What is your child's favorite food?
What food does your child dislike?
Can your child be relied upon to indicate bathroom wishes?
What words does your child use for: Bowel movements
What words does your child use for: Urination
What time does your child awaken
Does your child normally nap? If so, for how long?
CHILD'S HEALTH RECORD
A copy of your child's immunizations and current physical will be needed
General state of health
Doctor Information
Doctor's Name
Phone Number
Add
Remove
Dentist Information
Dentists Name
Phone Number
Add
Remove
Are your child's immunizations up to date?
Yes
No
Upload File
Drop files here or
Select files
Max. file size: 2 GB.
Please attach a copy of immunizations. This should include the signature of nurse or doctor who administered the immunizations/vaccines
Does your child have any known allergies?
Are you concerned that your child may be prone to any type of allergies?
Yes
No
Please explain:
Does your child have any medical conditions which we should be made aware of?
Has your child had or does he/she struggle with the following common childhood illnesses?
Asthma
Bronchitis
Chicken Pox
Constipation
Convulsions
Diabetes
Diarrhea
Fainting Spells
Frequent Colds
Frequent Ear Infections
Frequent Sore Throats
German Measles
Heart Disease
Hepatitis
Impetigo
Lice
Measles
Mumps
Polio
Ringworm
Scarlet Fever
Skin Rash
Soiling
Stomach Upsets
Tuberculosis
Urinary Problem
Whooping Cough
Worms
Please check all that apply
What time does your child go to sleep at night?
Do they sleep through the night?
Yes
No
Sometimes
Does your child sleep in a bed or crib, other?
Bed
Crib
Other
Are there any siblings? Please name them and specify ages and gender
Name
Age
Gender
Add
Remove
(+) Use plus icon to add more
Has your child had experience playing with other children?
Yes
No
What language(s) are spoken at home?
Does your child have any security objects such as a blanket, soother, bottle, toy, etc.?
What are your child's favorite activities, toys, books, or games?
Are there any other comments or information you would like to let us know about?
Will you be looking into applying for the Child Care Voucher program (Indiana Child Care Development Fund)? To qualify for CCDF in Indiana, a family's gross monthly income before taxes and any other deductions cannot exceed 127% of the federal poverty level.
Yes
No
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