Child Care Request Form

    Name 姓名*
    Address 地址
    Unit# 單位#
    City 城市*
    State 州
    Zip code 郵政編碼*
    Country 縣*
    Phone 電話
    Cell Phone 手機
    Email 電子郵件*
    Family Composition 家庭結構 *
    Single Parent 單親Two Parent 雙親Teen Parent 青少年家長Foster/Guardian 寄養父母/監護人Caller Declined to Answer 謝絕回答Other 其他Grandparent/Other relative 祖父母/其他親戚Unable to Determine 無法斷定
    Languages 語言*
    English 英語Spanish 西班牙語Chinese(Mandarin) 中文(國語)Chinese(Cantonese) 中文(粵語)Creole 克裏奧爾誘語German 德語Russian 俄羅斯語French 法語Hindi 印地語Hebrew 希伯來語Other 其他語種
    Child Name | DOB 小孩名字 | 性別 | 生日 *
    Type Of Care Needed 所需托兒類別*
    Child Care Center 托兒中心Family Child Care 家庭托兒Preschool Program 學前托兒School Age Program 學齡托兒(FCC)Group Family Care (家庭托兒)集體家庭托兒(FCC)Informal/Exempt (家庭托兒)非正式或法律豁免(CCC)Camp (托兒中心)夏令營(CCC)School (托兒中心)學校(FCC)In-Home/Exempt (家庭托兒)非正式或法律豁免
    Location of Care 托兒地點*
    Location of child Care needed if other than home (please specify zip code) 請指明住家之外的托兒地點郵區號碼
    Additional Care Needed 額外托兒服務
    Evening 晚上Ovemight 整夜Weekend 週末Mildly Ill/Sick 輕度生病或生病Snow Days 下雪天Respite Care 臨時照顧Rotating Schedule 輪換時間Part Week 半周制Non-Traditional Hours 非常規時間Breast Feedling Friendly 適於哺乳
    Special Needs 特殊需要
    Developmental Disability 發展障礙Educational Disability 學習障礙Medical Care Needs 需要醫療護理Wheelchair Access 輪椅通道Special Diet 特殊飲食Sign Language 手語Moderately Ill/Health Service 輕度生病或健康服務Transportation 交通Inclusive/Integrated 全包的/綜合的Itinerant 居無定所的人Gifted 天才班ADD 注意力不足多動症ADHD 兒童多動症AIDS 艾滋病HIV 人類免疫缺陷病毒PDD 全身性發育遲緩Behavioral 行爲問題Down Syndrome 唐氏綜合症Other(See Comments) 其他(參看注解)Speech Delay 語言發育遲緩
    Year Schedule 所需托兒時間段*
    Full/Part Time Care 全天/半天托兒*
    Days of Care 所需托兒*
    Monday 週一Tuesday 週二Wednesday 週三Thursday 週四Friday 週五Saturday 週六Sunday 週日
    Monday 週一
    Tuesday 週二
    Wednesday 週三
    Thursday 週四
    Friday 週五
    Saturday 週六
    Sunday 週日
    Family Size (1, 2, 3…) 家庭人數*
    Employment Status 就業情況*
    NY Income Guideline 紐約州收入參考*

    Below NY 200% of Poverty means your family size with income meet one of the following options ( 紐約200%貧困線以下意思是:您家庭人口總收入符合以下其中的一項選擇): Family Size 2 Income < $29,140, Family Size 3 Income < $36,620, Family Size 4 Income < $44, 100, Family Size 5 Income < $51,580, Family Size 6 Income < $59,060, Family Size 7 Income < $66,540, Family Size 8 Income < $74,020
    Subsidy Eligibility 資助資格*

    Income Eligible at County Level means your family size with income meet one of the following options (按郡的標準,收入合乎資格意思是:您家庭人口總收入符合以下其中的一項選擇): Family Size 2< $40,464, Family Size 3 < $47,256, Family Size 4<$50,280, Family Size 5<$58,872, Family Size 6<$67,476, Family Size 7<$76,080, Family Size 8<$84,672
    Your Relation To Child 你與小孩的關系*
    Reason For Seeking Child Care 尋找托兒服務的原因*
    Child's Development 兒童的發展Current Provider No Longer Available 現有的托兒人員停止服務Dissatisfied with Current Care 不滿意目前的托兒服務Employment 就業Other-Information On College 其他-大學資訊Parent's Non-Job Related Needs 家長非工作方面的需要Seeking Employment 找工作Training/Education 培訓/教育End Leave of Absence 請假到期Not Able to Determine 無法說明Other - DSS Training 其他-社安局培訓Other 其他Relocation/Moved 搬遷/搬家
    How Did You Hear About Us 你如何知道我們的服務*
    CCR&R Website 托兒咨詢轉介網站Child Care Provider 托兒人員Community Outreach/Event 社區拓展及活動CCR&R Outreach Event 托兒咨詢轉介拓展活動Employer 雇主Former Client 老客戶Client 客戶Internet 互聯網LDSS 當地社安局Media/Newspaper 媒體/報紙Other Private Agency 其他私家機構Other Public Agency 其他公共機構Parent Seminar 家長講座Phone Book 電話簿Private Agency/CBO 私家機構或社區組織Public Agency/CBO 公共機構或社區組織Regional 211 地區的211電話服務Regional 311 地區的311電話服務Relative/Friend 親戚或朋友Other CCR&R 其他托兒咨詢轉介Job Training Site 職業培訓處888 # 888電話服務Public Community Agency 公共社區機構Private Community Agency/CBO 私家社區機構或社區組織Case Worker 社會工作者AM New York AM紐約報Flyer 宣傳單Religious Organization 宗教組織Metro AD 大捷運廣告Other 其他
    what language do you prefer to receive the child care referral package from us 您希望收到我們提供給您的托兒資料是*
    Comments 其它信息补充
    Disclaimer:Providers in this report were selected using the criteria supplied by you. While we make every effort to supply you with accurate information, most of this data was supplied by the referenced providers. These providers are referrals, not recommendations. You should always visit providers before deciding on child care.
    附件中之托兒人員名單乃根據閣下提供的準則而選取。 大部份資料均來自托兒人員,我們會盡力為您提供準確的資料。我們只作資源轉介,而非推薦個別托兒人員,故此閣下於入托前應先跟托兒人員面談洽商。
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