Intact Family Services Child Care Referral Form Instructions
This form contains 44 fields organized into 13 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Fifth Child Information | ||
| Fifth Child's Name | Text |
Enter the full name of the fifth child, with the last name followed by the first name.
|
| Fifth Child's Date of Birth | Date |
Enter the date of birth for the fifth child.
|
| Fifth Child's Relationship to Applicant | Text |
Enter the fifth child's relationship to the applicant.
|
| Fifth Child's End Date of Child Care | Date |
Enter the end date of child care for the fifth child, if known.
|
| First Child Information | ||
| Child's Full Name | Text |
Enter the full name of the first child, starting with the last name, then the first name.
|
| Child's Date of Birth | Date |
Provide the first child's date of birth.
|
| Relationship to Applicant | Text |
Specify the first child's relationship to the applicant.
|
| Child Care End Date | Date |
Enter the end date of the first child's child care services, if known.
|
| Fourth Child Information | ||
| Fourth Child's Name | Text |
Enter the full name of the fourth child in the format 'Last, First'.
|
| Fourth Child's Date of Birth | Date |
Provide the date of birth for the fourth child.
|
| Fourth Child's Relationship to Applicant | Text |
State the relationship of the fourth child to the applicant.
|
| Fourth Child's Child Care End Date | Date |
Provide the end date of child care for the fourth child, if known.
|
| Mailing Address | ||
| Mailing Address | Text |
Please provide the complete mailing address, if it is different from the residence address. Fill only if 'Residence Address Line 1' is different than residence.
Depends on:
Residence Address Line 1
|
| Primary Applicant's Email Address | ||
| Primary Applicant Email Address | Text |
Please provide the primary applicant's email address.
|
| Primary Applicant's Name | ||
| Primary Applicant First Name | Text |
Please enter the primary applicant's first name.
|
| Primary Applicant Last Name | Text |
Please enter the primary applicant's last name.
|
| Primary Applicant Middle Initial | Text |
Please enter the primary applicant's middle initial.
|
| Primary Applicant's Phone Numbers | ||
| Daytime Phone Number | Text |
Please enter the primary applicant's daytime phone number.
|
| Cell Phone Number | Text |
Please enter the primary applicant's cell phone number.
|
| Primary Applicant's Residence Address | ||
| Residence Address Line 1 | Text |
Please enter the primary applicant's full street address, including building number and street name.
|
| Residence City | Text |
Please enter the city of the primary applicant's residence.
|
| Residence State | Text |
Please enter the state of the primary applicant's residence.
|
| Residence Zip Code | Text |
Please enter the zip code of the primary applicant's residence.
|
| Referral Worker and Case Information | ||
| DCFS/POS IFS Worker Name | Text |
Enter the full name of the DCFS/POS IFS worker.
|
| Worker Phone Number | Text |
Enter the phone number for the DCFS/POS IFS worker.
|
| Worker Email Address | Text |
Enter the email address for the DCFS/POS IFS worker.
|
| Case CYCIS Number | Text |
Enter the Intact Family Services case CYCIS number.
|
| Case Closure Date | Date |
Enter the projected closure date for the Intact Family Services case.
|
| Second Child Information | ||
| Second Child's Name | Text |
Please enter the full name of the second child, including last and first name.
|
| Second Child's Date of Birth | Date |
Please provide the date of birth for the second child.
|
| Second Child's Relationship to Applicant | Text |
Please specify the relationship of the second child to the applicant.
|
| Second Child's End Date of Child Care | Date |
Please provide the end date of child care for the second child, if known.
|
| Seventh Child Information | ||
| Seventh Child's Name (Last, First) | Text |
Enter the full name of the seventh child for whom child care services are being requested, in the format Last, First.
|
| Seventh Child's Date of Birth | Date |
Enter the date of birth for the seventh child.
|
| Seventh Child's Relationship to Applicant | Text |
Enter the relationship of the seventh child to the applicant.
|
| Seventh Child's End Date of Child Care (if known) | Date |
Enter the end date for child care services for the seventh child, if known.
|
| Sixth Child Information | ||
| Sixth Child Name | Text |
Enter the full name of the sixth child requiring child care services, in the format Last Name, First Name.
|
| Sixth Child Date of Birth | Date |
Provide the date of birth for the sixth child.
|
| Sixth Child Relationship to Applicant | Text |
State the relationship of the sixth child to the applicant.
|
| Sixth Child Care End Date | Date |
Enter the known end date for child care services for the sixth child, if applicable.
|
| Third Child Information | ||
| Third Child's Name | Text |
Enter the full name of the third child for whom child care services are requested, in the format Last Name, First Name.
|
| Third Child's Date of Birth | Date |
Enter the date of birth for the third child.
|
| Third Child's Relationship to Applicant | Text |
State the relationship of the third child to the applicant.
|
| Third Child's Child Care End Date | Date |
Enter the end date of child care for the third child, if this information is known.
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