If you operate a child care home, please tell us your name:

 First Name:       Last Name:

If you operate a child care center, pre-school or school age program, please tell us the name of the program:

        Program Name:

Please fill in your DHS License Number*:

     (Your "K8" number)

In the comment box below, please tell us what you need to

change about your program.  Be specific.  If you have

openings, please tell us how many and in what age group.*

Your e-mail address*: 

For web-based referrals, would you like to have your information

available for parents using the Child Care Connector?*

Yes No

When you are finished, please click on the "Submit" button. 

Your information will be submitted directly to a Referral Specialist.

If we have questions regarding your changes, we will e-mail or call you.

*Indicates REQUIRED Fields