Section One - Parent/Guardian Information: 

Different Address to Search other than Home or Work?

How Can We Contact You?

NEW!  We now offer a FREE monthly on-line newsletter, "Parent Central", filled with parenting tips, resources and more.  Would you like to sign up for this e-newsletter (you can unsubscribe at any time)?

Yes, Send Newsletter                No, Do Not Send Newsletter

Where do you need this child care:   Close to Home Close to Work Close to School Close to Home AND Work

Number of children in your family: 

Section Two -

Information about Child(ren) You Need Care For:

Child #1

Name:      Gender:  Female Male

Birth Date:  

Date Care is Needed: 

Days Care is Needed: (check the days you need, then fill in the times)

Does this child need any of the following? (check any that apply)

Drop In Care             After School Care        24-hour care

Rotating Schedule    Before School Care

Temporary/Emergency Care

Child #2

Name:      Gender:  Female Male

Birth Date:           

Date Care is Needed: 

Days Care is Needed: (check the days you need, then fill in the times)

Does this child need any of the following? (check any that apply)

Drop In Care            After School Care    24-hour care   

Rotating Schedule    Before School Care

Temporary/Emergency Care

Child #3

Name:      Gender:  Female Male

Birth Date:           

Date Care is Needed: 

Days Care is Needed: (check the days you need, then fill in the times)

Does this child need any of the following? (check any that apply)

Drop In Care              After School Care    24-hour care

Rotating Schedule    Before School Care

Temporary/Emergency Care

Child #4

Name:      Gender:  Female Male

Birth Date:           

Date Care is Needed: 

Days Care is Needed: (check the days you need, then fill in the times)

Does this child need any of the following? (check any that apply)

Drop In Care                After School Care        24-hour care

Rotating Schedule      Before School Care

Temporary/Emergency Care

Section Three - Information About Desired Child Care Program

Type of Care Care Program Desired: (check any or all that apply)

Environment (choose any that apply):

Do you need a Language spoken other than English?

No        Yes - please specify: 

Does your child (children) have any special needs?   (check any that apply)

Program Rating Request:  (check any that apply)

Program Subsidies/Financial Assistance: (check any you need)

Do any of your children attend school? 

No        Yes - list schools: 

Transportation Needs: 

Section 4 - Additional Information About You

Your Age:  Under 20 years 20-29 years 30-39 Years 40-49 years 50 or over

Relationship to Children listed above: Father Mother Grandparent Guardian Relative Foster Parent Other

Current Employment Status: Employed Seeking Employment At Home Student TANF

Family Income (Yearly):  Up to $28,000 Greater than $28,000 Choose not to answer  

Family Size:   Two Three Four Five Six Seven Eight Nine or More

Number of Adults in Home: One Adult Two or More Adults

Referred to CCRC by:  Advertisement DHS Employer/Co-Worker Friend/Relative Inter-Agency Other R&R agency Provider Walk-In Web Page Yellow Pages

Reason for Seeking Child Care:  End of Leave of Absence Looking for Work Work School Child's Needs Parent's Needs Current Care Closing Asked to Leave Care Unhappy with Quality of Care Cost too High

Section 5 - Census Data We Need

(this section is completely optional, but we would appreciate your answers)

Are You Spanish/Hispanic/Latino?   Choose Not to Answer No Yes, Mexican, Mexicana American or Chicano Yes, Puerto Rican Yes, Cuban Yes, Other

What is Your Race?    Choose Not to Answer Caucasian African American American Indian/Alaskan Native Asian Indian Native Hawaiian Chinese Filipino Japanese Vietnamese Other Asian Guamanian or Chamorro Samoan Other Pacific Islander Other Race

Do you speak a language other than English at Home? Yes No

If yes, what language? 

Finally, how did you hear about this on-line referral form? (pick one):

Search Engine

Another website (for example, OCCRRA or NACCRRA)

Friend 

Our phone line

Your Employer     

Other  (Please describe) 

You are finished! 

Thank you for completing this form.

Now, please hit the "submit" button to send us

your information.