Referral Intake Form
Please fill out all information below.  You are also welcome to call us at (815) 758-8149 ext. 241 or email us at 4creferrals@four-c.org.

4-C does not endorse or recommend one provider over another, nor can we guarantee they provide quality childcare.
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First Name *
Last Name *
Street Address *
City *
State *
Zip Code *
Phone number *
Email *
What County do you live in? *
What towns are you looking for childcare? *
Employer/School (reason for care) *
Care Schedule *
Required
What kind childcare are you looking for?
Clear selection
What date  are you looking to start childcare? *
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What is the earliest time for drop-off? *
Time
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What is the latest pick up time? *
Time
:
Child 1 Name *
Child 1 Date of Birth *
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DD
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YYYY
Child 2 Name
Child 2 Date of Birth
MM
/
DD
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YYYY
Child 3 Name
Child 3 Date of Birth
MM
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DD
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YYYY
If you have any additional children that need care please add their Name and Date of Birth here.
Do any of your children have any special needs? Such as Behavioral, Social/Emotional or Physical Delays? If so, please explain briefly below.
Do you currently have a case with the Child Care Assistance Program (CCAP)?
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If not, are you interested in more information on the income based state subsided childcare assistance program?
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We will email you a list of childcare providers would you like them mailed out as well? *
Would you prefer a phone call or email from a specialist? *
Statistical Information
The following statistical questions are for reporting purposes only.  The following information is confidential.
Are you employed or going to school?
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Family Size
Number of Adults in home
Age?
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Were you or are you currently in the Military?
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Do the Children have health insurance?
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How were you referred to 4-C?
What languages do you speak at home?
Is there any additional information you would like the referral specialist to know regarding your childcare search?
Do you feel safe at home? *
Do you have permanent housing? *
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