Episcopal Children's Services | ECS

ECS Referral Request Form

How the referral process works: Our computer will generate referrals based on a match between your needs and providers in our database. After you submit an online request, we will generate a referral listing with a packet of information to help you in your choice. We can e-mail or mail you this information, or you can pick it up in person at your local R&R office. Please check below how you would like to receive your referrals and informational packet (Email, Postal Mail, Pick-Up)

All information you submit is strictly confidential. Only the School Readiness Agency and/or the Florida Department of Law Enforcement may request information relating to your eligibility and/or make an inquiry on information given. Hover over underlined field names for more information.

* Required Field

Information Delivery
*Pick-up Method:	Email US Mail In Person Pick-Up

Applicant Information
*Last Name:
*First Name:
Middle Initial:
*Email:
Date of Birth:	Month: Day: Year (yyyy):
Gender:	Male: Female:
*Address Line 1:
Address Line 2:
*City:
*State:
*Zip Code:
*County:
*Home Phone:
Other Phone:

Employment Information
Employer Name:
Employer Address Line 1:
Employer Address Line 2:
Employer City:
Employer State:
Employer Zip Code:
Employer Phone:

Other Information
*Reason For Care:	Customer Asked To Leave Program Caregiver No Longer Available Cost Too High End Leave of Absence Employment / Working Parent's/Child's Needs Unhappy With Quality Relocation Training / Education Hurricane / Disaster Prefer Not To Answer Other

*Childcare Issues:	Affordability / Cost Care Ending Curriculum / Program Location / Trasnportation No Openings Quality Schedule Special Needs Type Of Care Prefer Not To Answer None
*Household:
*Relationship:
Income:

Referred By:	Newspaper / Magazine Billboards Brochure / Poster Department of Children & Families Employer / Business Children's Forum Friend / Relative Yellow Pages Office of Early Learning Licensing Radio Ad Early Learning Coalition School / Provider Television Web Site Word Of Mouth Other

Child Information
*Last Name:
*First Name:
Middle Initial:
*Date of Birth:	Month: Day: Year (yyyy):
Gender:	Male: Female:
*Special Needs:	Yes: No:
Special Needs Services Needed: (Required if you selected "Yes" above)	ADD / ADHD Allergies (Severe) Asthma (Severe) Autism Spectrum Disorder Behavioral Disorder (Severe) Cystic Fibrosis Developmental Delay Diabetes Hearing Impairment Mental Disability / Delay Speech / Language Delay Medically Challenged / Delayed Physical Disability / Delay Seizure Disorder Visual Impairment Other

*Days Needed:	Sunday Monday Tuesday Wednesday Thursday Friday Saturday
*Start Time Needed:	: AM: PM:
*End Time Needed:	: AM: PM:
Need to add more children to your referral? Check here:

Additional Details
*Schedule:	24 Hour Care After School Both Full-Time & Part-Time Before School Drop-In Care Emergency/Temporary Care Evening Care Full-Time Full Year Morning Open In Safe Weather Overnight Part-Time Rotating Summer Only School Year Vacation / Holidays School System Weather Days Weekend Care

*Programs:	Child Care Center Family Child Care Home Head Start Nanny / Au-Pair Play Group Non-School Based School Readiness School Age Program School-Based School Readiness Summer Camp

The information fields below are available to further customize your search. If you would like to complete these fields, please do so below, but know that the more you select, the fewer leads will be generated.
Curriculum/Learning Program:	No Preference A-BEKA Developmentally Appropriate Beyond Centers & Circle Time Character Based Creative Curriculum High Reach High Scope Montessori Research Based Religious Waldorf WEE Learn Other

Provider Type:	Licensed License Exempt Registered SubContracted Gold Seal Accreditation

Environment:	Air Conditioned Bi-Lingual Elevator Faith-Based Center Fenced Yard Inclusionary Setting No Pool No Pets Operation Child Care Outdoor Play Pet On Site Pool On Site Sick Child Care Offered Sign Language Smoke Free Spa Teen Parent Program Wheelchair Accessible Other

Transportation:	From Child's Home Near Public Transportation To Child's Home Transportation Provided In Walking Distance To School

Enhanced Services:	Computers Arts & Crafts Family Environment Field Trips Gymnastics / Dance Lessons Health / Social Services Homework Tutor Kindergarten Class Music Lessons On-Site Screenings Outdoor Sports Small Group Size Special Needs Enrolled Swim Lessons Therapeutic Services

Other Information Requested:	Emergency Family Services / 211 Other Referrals Parent Education / Training Information Hurricane / Disaster

Our Programs

ECS Referral Request Form