5/1/2020
p. 1
CHILD CARE REFERRAL FOR CRITICAL/ESSENTIAL WORKERS
During the COVID-19 Pandemic
I confirm that I have a current unmet child care need due to the COVID-19 Pandemic. Yes No
PROGRAM COMPONENTS (Tell us the # of children in each age group that have unmet childcare need)
____
INFANT (6 weeks to 16 months)
___
_TODDLER (16 to 33months) ____
PRESCHOOL (33 months. to 5 years)
____Kindergarten to 8 years
____9 years up to 12 years
• Days of the Week you need care (check all that apply): Mon Tue Wed Thu Fri Sat Sun
• Time of Day you need care (Check all that apply)
Day Hours: ____6:30 am – 6:00 pm Extended Hours: ____6:00 pm – Midnight ____Midnight – 6:00 am
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PARENT/GUARDIAN CONTACT INFORMATION
First Name _____________________________________________ Middle Initial ____________ Last Name ______________________________________________________________
Address _______________________________________________________________ City____________________________________________________ State___________Zip____________________
Preferred phone # ___________________________________________________________________________ Emergency Ph # _____________________________________________
Preferred E-ma
i
l____________________________________________________________________
_____
Work phone (_______________________________________________
Department and Position:________________________________________________________________________________________ Employee ID # _________________________________________
Date ___________________________________
Disclaimer: The information you provide may be shared with Ramsey County departments, as well as
providers that you agree we contact such as the YMCA child care centers, licensed Family Child Care
providers, providers coordinated through Parent Aware or other providers in order to help coordinate a
referral to child care. By providing the information below you are authorizing Ramsey County to release this
information to the child care provider you choose. You are not legally required to consent to the release of
this information, but Ramsey County will not be able to assist with child care referrals on your behalf
without your consent. By clicking the Submit button you are giving your consent to share this information.
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If Yes, please share why there is an unmet need:
Childcare closed
Family member no longer able to care
School District denied service
Other (please explain):
If No, you do NOT need to fill out this form. At
this time the COVID Child Care Team is only
assisting staff with a CURRENT child care need.
When you find that your child care options are no
longer available, you may return to complete this
form at that time. Thank you. Be well!
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