Referral Request Form

To request a free child care referral please complete this form and email it to:  
 
geninfo@stlawrencechildcare.org
or print and FAX it to (315) 394-6809  

You may also mail or bring it to our office:  
St. Lawrence Child Care Council 
314 Ford Street 
Ogdensburg, NY 13669  

If you need assistance with this form please call (315) 393-6474  

For information about the different types of child care programs in St. Lawrence County visit the parent’s page of our website at www.stlawrencechildcare.org   

The information you provide will help our referral counselor search for child care services that best match your family’s needs.  

You will receive information on at least three child care programs and educational materials that match the criteria you provided to our referral counselor.   

The SLCCC does not provide recommendations to child care providers.  The provider names and information you receive are referrals only. Just because a program is registered or licensed it does not always ensure quality care. We encourage you to visit several providers before making your final choice.  Ask for references and contact them to see what they think about the provider you are thinking of using. You are the best person to decide whether the provider and quality of the program is right for your child.  

SLCCC employees will keep all customer information confidential. The Information you provide is used to give you individualized services and to gather statistical information. Specific customer data is kept private at all times. No personal information will be shared without your written consent.  

If you have any questions or need assistance completing this form,
please contact Dee Burlingame at (315) 393-6474 or 1-800-246-5352. 
Our office is open and referrals are available Monday – Friday from 8:30am - 4:00pm

Your comments and/or suggestions are important to us.  Please let us know if our services met or did not meet your needs. After you receive your referrals, please complete the parent referral service evaluation located on the Parent Page of our website at www.stlawrencechildcare.org 

For more information concerning any child care program, please visit: www.ocfs.state.ny.usor call the New York State Office of Children and Family Services Syracuse Regional Office at: (315) 423-1202    

Thank you for choosing the St. Lawrence Child Care Council to help you in your child care search.


*
*
General Information
Address (parent)

Family Composition

Mailing (if different than above)


Parent Information
Financial Assistance? (Do you receive any Public Assistance?)


Child General Information
Gender
Gender
Gender
Gender
Care Needed
Care Needed
Days Care Needed
Extra Care Services
Type of Care (See Types of Care Explanation on the Website)
Environment
Languages (Check the language(s) you want the provider to accommodate)
Special Needs (Check if you need your provider to accommodate any of the following for your child(ren)
Medication MAT (Check if you need your provider to administer medications)
Program (Specify what type of program for your child(ren)
Additional Care Services (Check if you need care for any of the following)
Transportation (Identify if you need your provider to accommodate any of the following)
Statistics General
Relation to Children
Employment Status
Adults
Income Category
Check the line based on your family size if your income is above or below the amount indicated
Child Health
Are children covered by health insurance?
Statistical Information (this is optional and data is used for statistical information only)
Are you Spanish/Hispanic/Latino?
Do you speak a language other than English at home?