Lafayette-Louisville-Superior-Erie-Leyner Family Intake Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Welcome to our intake form! The Early Childhood Council of Boulder County(ECCBC) is the local Childcare Resource and Referral (CCR&R) office. We are referring families who need care to programs who have slots. Filling out this form does not guarantee placement. By submitting this form, you are requesting a list of providers who may be able to care for your children. You will be expected to reach out to the providers on this list and complete the enrollment process with them. After completion of this form, someone from ECCBC will strive to be in touch within 24 business hours.

Parents and guardians looking for childcare slots in the following zip codes, please fill out this form: 80025, 80026, 80027, 80516.

If you would prefer to leave a verbal message about your needs, please call 720-263-2145. We will strive to be in touch within 24 business hours.

For information on the programs you may be referred to, please visit Colorado Shines and enter the program name and city to review their profile. https://www.coloradoshines.com/search

Parent/Guardian name(s) *

Email address *

Phone number *

How would you like to be contacted?

Phone

Text (by checking this box, you are opting in to receive text messages)

Other:

Are you an essential worker?

Yes

Not sure

Clear selection

Is your family using CCAP (Colorado Childcare Assistance Program) to help pay for childcare? *

Yes

Not Sure

Please send me information on CCAP

Required

In which city do you need care? *

On what date do you need care to start? *

Is this care only needed for a short time/temporarily?

Yes

Maybe

Clear selection

Please check all types of care your are interested in being referred to. *

Licensed Family Child Care (ages 0-12)

Childcare Centers/Preschools (ages 0-6)

School Age Programs (ages 6-12)

Informal Care options

Required

For what reason do you need care?

My previous childcare provider/school closed due to Stay-at-Home orders.

My previous childcare provider/school closed/ended for another reason.

My previous childcare provider/school closed permanently.

My previous care provider is considered high-risk for COVID-19 and stopped providing care.

I did not need care previously.

Other:

Is lack of childcare preventing you from returning to work? *

Yes

Maybe

Birth date of Child #1 who needs care *

YYYY

Please list any special needs for Child #1

Amount of care needed for Child #1 (check all that apply) *

Mon

Tues

Wed

Thurs

Fri

Sat

Sun

Drop-in

None

Evening

Overnight

Birth date of Child #2 who needs care

YYYY

Please list any special needs for Child #2

Amount of care needed for Child #2 (check all that apply)

Mon

Tues

Wed

Thurs

Fri

Sat

Sun

Drop-in

None

Evening

Overnight

Birth date of Child #3 who needs care

YYYY

Please list any special needs for Child #3

Amount of care needed for Child #3 (check all that apply)

Mon

Tue

Wed

Thurs

Fri

Sat

Sun

Drop-in

None

Evening

Overnight

Birth date of Child #4 who needs care

YYYY

Please list any special needs for Child #4

Amount of care needed for Child #4 (check all that apply)

Mon

Tues

Wed

Thurs

Fri

Sat

Sun

Drop-in

None

Evening

Overnight

If you have more than 4 children you need care for, please check this box and we will reach out for further details.

I have more than 4 children I need care for.

I would like information on the following supports that may be available to me.

Food

Housing

Medical/Dental

Mental Health Supports

Other:

I give ECCBC permission to share my contact information only (parent name, email/phone) with licensed childcare programs in Boulder County. *

Yes

No, I will contact providers myself

I understand and agree that ECCBC will not share individual information submitted here with other county partners but will use and share totals collected here for its work. For example, we will be counting the number of families needing care in Lafayette without sharing who specifically needs care. *

Yes

Please explain when you reach out to me

Required

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms