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Squirrel Intake Form
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1.
Parent Information
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2.
Children Information
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3.
More Information
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Parent Information
ERC is the licensed child care resource and referral agency that assists families in locating child care in Shawnee, Jackson, Osage, Wabaunsee and Pottawatomie counties. The listings include regulated family child care providers, centers, pre-schools and school-age programs. If you would like assistance in locating openings, ERC is here to help, free of charge. Please fill out the form and send it to ERC, either by mail, fax or e-mail.
Name of Squirrel Parent
Address
City
State
Zip
Daytime Phone Number
Fax Number
Email Address
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Children Information
Number of Squirrels Needing Care
Birthdates of Squirrels Needing Care
Days Care is Needed (Please select all that apply)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Hours Care is Needed
Date Care is Needed
Do You Have SRC Assistance
*
Yes
No
Please Provide Location That Would be Best for Your Squirrel Care Needs
Please List Any Special Needs Your Squirrel May Have
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More Information
Please Specify How You Would Like to Receive the Referrals
Telephone
*
Yes
No
Mail to Home
*
Yes
No
Fax
*
Yes
No
Email
*
Yes
No
ERC has not personally interviewed or screened the referrals. It is the responsibility of the family to research all options and to require references in the selection process. The names you receive are referrals only; not recommendations or endorsements of ERC. To help you through the selection process, ERC will also send you a packet of information which includes tips for selecting good quality child care as well as regulation information.
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