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.

First and last name*

Answer required for "First and last name"

Street address*

Answer required for "Street address"

City*

Answer required for "City"

City or Zip code in which child care is needed*

Answer required for "City or Zip code in which child care is needed"

Preferred phone number*

Number Required

Preferred method of contact

Answer required for "Preferred method of contact"

Phone

Best time to contact

Answer required for "Best time to contact"

Number of children for whom care is needed*

Answer required for "Number of children for whom care is needed"

Ages of children for whom care is needed*

Answer required for "Ages of children for whom care is needed"

Language preference*

Answer required for "Language preference"

English

Spanish

Chinese

Other:

Special needs*

Answer required for "Special needs"

Yes

If yes, please explain:

Answer required for "If yes, please explain:"

Day(s) care is needed*

Check all that apply

Answer required for "Day(s) care is needed"

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Hours needed*

Answer required for "Hours needed"

Part-time

Full-time

Drop-in

Evenings

Variable

Times care is needed*

(Please indicate time range; i.e., from 8 a.m. to 4 p.m.)

Answer required for "Times care is needed"

Location of care*

Answer required for "Location of care"

Near home

Near work

Type of child care*

Check all that apply

Answer required for "Type of child care"

Center

Family child care home provider

Reason for care*

Check all that apply

Answer required for "Reason for care"

Work

School

Looking for work

Other:

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

Please fix the highlighted areas below before submitting.

Referral inquiry form