Child Care Referral Form
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1EXHIBIT I
Non-TANF Refugee Services
CHILD CARE REFERRAL
1. To: Early Learning Coalition of Miami-Dade/Monroe
2. Date of Referral _______________________________________
3. Address of Eligibility Center ___________________________________________ Phone#:_________________________
4. Parent’s Name
_________________________________________________________
DOB: ______________________________
5. a. Address
_____________________________________________________________________________
Phone: _______________
6.
7. Parent’s Date of Entry into
8. Country of Origin
Parent’s Alien Number
U.S
____________________________________
__________________________
_____________________________
nd
nd
nd
9 .Spouse / Second Parent Name if in
10. Spouse/2
Parent’s Alien #
11. Spouse/2
Parent’s Date of
12. Country of Origin of 2
the Home
Entry into U. S
Parent
______________________________
__________________________
___________________________
______________________
13. Services Currently Being Received By Parent: _____________________________________________________________
(i.e. Medicaid, TANF Support Services, etc.) _____________________________________________________________
14. Referral Source (i.e. Employment, Adult Ed., Match Grant):
(Select one)
Employment Provider
Adult Education Provider
Match Grant Provider
15. Priorities:
(Select one)
First - Currently employed and placed by an Employment Provider or Match Grant Program.
Second - Currently enrolled full-time in Adult Education classes.
Third - Currently enrolled part-time in Adult Education classes or ESOL.
Fourth - Currently enrolled with an Employment Provider or Match Grant Program and is actively seeking employment.
18. Employed 6 mo.
16. Date of employment or enrollment in
17. Employed at Date of Referral
Yes
No
an employment or adult education
program.
_________________________
19. Termination Date ________________
ESOL or Adult Education registration
Family Size:____________
period: ___________________________
20. Reason:
Employment Location
Address
Phone
Parent:____________________________
____________________________________________________
_____________________
nd
2
Parent :_________________________
____________________________________________________
_____________________
21. Names of Children
22. Date of Birth
23. Social Security # (If Available)
24. Alien #
__________________________________
______________________
___________________________
_______________________
__________________________________
______________________
___________________________
_______________________
__________________________________
______________________
___________________________
_______________________
__________________________________
______________________
___________________________
_______________________
25. Copy of current immunization record
26. Copy of Child(ren)’s Birth Certificate
Attachments:
27. Copy of Child(ren)’s physical examination record (completed within last 12 mos.)
28. Copy of USCIS Documentation showing refugee/entrant status (If Available)
29. Copy of Social Security Cards (If Available)
Comments: _____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
30. Name & Telephone # of Referring Agency
_______________________________________________
_______________________________________
Signature of Representative
Date Form Completed
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