Early Learning Resource Center Region 7 Rapid Response Team Referral
The Rapid Response Team (RRT) is dedicated to supporting children, families, and licensed child care providers when challenging behaviors occur in the classroom. RRT is a short-term solution, providing classroom observations and strategies to prevent children from being suspended or expelled from the early childhood setting.
Referral Date
*
-
Month
-
Day
Year
Date
Your Full Name
*
First Name
Last Name
Your relationship to the child (parent, teacher, child care director, etc.)
*
Child's Full Name
*
First Name
Last Name
Child's Date of Birth
*
-
Month
-
Day
Year
Date
Sex of Child
Please Select
Male
Female
Ethnicity of Child
Please Select
Hispanic
Non-Hispanic
Black or African American
American Indian/Alaskan Native
Asian
Native Hawaiian/Pacific Islander
White
More Than 1 Ethnicity
Unknown
Other
Parent/Caregiver Name
*
First Name
Last Name
Parent/Caregiver Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Caregiver Phone Number
*
Please enter a valid phone number.
Parent/Caregiver Email
example@example.com
Child Care Program (including location name if more than one site)
*
Child Care Contact Name
*
First Name
Last Name
Child Care Contact Phone Number
*
Please enter a valid phone number.
Child Care Contact Email
example@example.com
Child Care Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Child Care Program County
*
Please Select
Lycoming
Clinton
Tioga
Child Care Program Type
*
Please Select
Center
Family
Group
Head Start/Early Head Start
Other
Child Care Program STAR Level
*
Please Select
STAR 1
STAR 2
STAR 3
STAR 4
Other
Child's Age Range
*
Please Select
0-24 Months
25-36 Months
37-60 Months
61-72 Months
73+ Months
Please choose any that currently apply to the child
*
IEP
IFSP
Additional services receiving
None
Please describe the services the child is already receiving
*
Has the child EVER been suspended from an ECE program?
*
Yes
No
Unknown
Has the child EVER been expelled from an ECE program?
*
Yes
No
Unknown
Please describe the concern for which you are seeking support, be as specific as possible
*
Is the parent/caregiver aware of this referral?
*
Yes
No
Unknown
How did you hear about the Rapid Response Team?
Please Select
Flyer/Brochure
Quality Coach
Director's Meeting
ELRC Website
Referred by another agency
CCW Caseworker
Submit
Should be Empty: