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Child Care Referrals



FAMILY INFORMATION
Please enter your family information below. Once you have completed this, you may then enter information for a child in the section labeled, 'Child Information'. If you wish to add another child once this is complete, you may do so by clicking on the 'Add Another Child' link at the bottom of this page. If you only need to enter one child then you may use the 'Click here to show Referrals' link at the bottom of the page.

* = Required Field

Your Name
First:  
 
Last:  
 
Email Address
Email Address:
 
Phone Numbers
Home Phone:*
Check this box if above is a cell phone
Alternate Phone:
Check this box if above is a cell phone
 
Preferred Notification Method
Email
Phone Call
Text Message
 
Preferred Language for Notification
English
Spanish
 
Your Location *
Please select the city and enter the zip code where you live.
City:       Zip Code:      

Have you received a referral in the recent past? *
Click 'yes' if you have requested a referral for your child between 10/01 - 12/31: 

Location Where Care is Needed *
Select the city OR enter a zip code where your children will need child care services.
City:  
Or Zip Code:  

Reason(s) Care is Needed *
Select the reason(s) that you need child care from the list below.
Hours of Care Needed*
Enter the hours of care that your children will require child care services.
Start Time: 
Stop Time: 

Language(s) Spoken by Provider *
Select the language(s) that you wish the provider to speak from the list below.



CHILD INFORMATION
Enter Child information below. If you wish to add another child once this is complete, you may do so by clicking on the 'Add Another Child' link at the bottom of this page. If you only need to enter one child, you may use the 'Click here to show Referrals' link at the bottom of the page.

Age of Child When Care is Needed *
Year(s)    Month(s)    Will the child be in kindergarten at this time? 

Child Care is Needed *
Preferred Provider Type *

Pick-up/Drop-off at School?
Select yes if your child will need to be picked up and/or dropped off at school.
If yes, then please select a school:
Special Needs *
If your child has special needs, please select from the list below.

Days of Care Needed *
Weekly Schedule Requirements *

Annual Schedule Requirements *



CHILDCARE PROVIDER INFORMATION
For informational purposes only:
Check this box if you’re interested in reading any complaints filed against referred provider(s).
Check this box if you're interested in seeing the QRIS quality score for referred provider(s).
Check this box if you're interested in knowing if referred provider(s) have streaming cameras.
Check this box if you're interested in knowing if referred provider(s) accept childcare subsidies.

Add Another Child | Click here to show referrals