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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 below 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:  

Heard About *
Please select how you heard about us:      

Your Location *
Please select the city and enter the zip code where you live.
City:       Zip Code:  

Location Where Care is Needed *
Select the area where your children will need child care services.
Area:  

Reason(s) Care is Needed
Select the reason(s) that you need child care 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 then 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?  Yes  No


Days of Care Needed
Monday  Tuesday 
Wednesday  Thursday 
Friday  Saturday 
Sunday 
Weekly Schedule Requirements *
Full Time  Part Time 
Before School  After School 
Drop In   Variable/Flexible 
Overnight  Evenings 
Other 

Annual Schedule Requirements *
Full Year  School Year  Summer Only  Other 
Add another Child | Click here to show referrals