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Referral inquiry form

Parents seeking child care are invited to complete this form, and a staff member from Child Care Services will contact you as soon as possible. Thank you.

Preferred method of contact
Answer Required
Language preference*
Answer Required
Special needs*
Answer Required
Day(s) care is needed*
Check all that apply
Answer Required
Hours needed*
Answer Required
Location of care*
Answer Required
Type of child care*
Check all that apply
Answer Required
Reason for care*
Check all that apply
Answer Required
Do you need assistance paying for child care?*
Answer Required
Are you an essential worker?*
Answer Required

Thank you!  We will be in contact with you soon.

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