Childcare Resources and Referral Form

Please complete this form in it's entirety and click the submit button at the bottom of the page. A Coalition representative will contact you shortly.

Applicant Information:

First Name: First Name is required.

Last Name: Last Name is required.

Email Address An email address is required.

Mailing Address:

City: State: Zip:

Home Phone

Other Phone:

Date of Birth:

Gender:

Household Information:

17 & Under Living on Own
More than 2 Adults
Two Adults
One Adult
I Prefer Not to Say

Relationship:

Parent | Stepparent
Foster Parent
Legal Custodian
Relative
Teen Parent
Other
I Prefer Not to Say

Child 1 Information:

First Name

Last Name

Date of Birth:

Gender:

Special Needs? Yes No

School:

Transportation? To From

Days Needed: MON TUE WED THU FRI SAT SUN

Time Needed: From: To:

Child 2 Information:

First Name

Last Name

Date of Birth:

Gender:

Special Needs? Yes No

School:

Transportation? To From

Days Needed: MON TUE WED THU FRI SAT SUN

Time Needed: From: To:

Child 3 Information:

First Name

Last Name

Date of Birth:

Gender:

Special Needs? Yes No

School:

Transportation? To From

Days Needed: MON TUE WED THU FRI SAT SUN

Time Needed: From: To:

Child 4 Information:

First Name

Last Name

Date of Birth:

Gender:

Special Needs? Yes No

School:

Transportation? To From

Days Needed: MON TUE WED THU FRI SAT SUN

Time Needed: From: To:

Reason for Care:

Parent | Child Needs
Caregiver No Longer Available
Cost Too High
Customer Asked to Leave Program
Employment | Working
End of Leave of Absence
Hurricane | Disaster Assistance
Job Search
Other | Unknown
I Prefer Not to Answer
Relocation
Training | Education
Unhappy with Quality

Childcare Issues:

Problems Finding Care
Affordability | Cost
Care Ending
Curriculum | Program
Location | Transportation
I Prefer Not to Share
No Openings
None
Quality
Schedule
Special Needs
Type of Care

Schedule Type Requested: (Days | Times Care is Needed)

24 Hour
After School
Before School
Full Time | Part Time
Drop In
Emergency or Temporary
Evening
Full Time
Full Year
Morning
Open in Safe Weather
Overnight
Part Time
Rotating
School System Weather Days
School Year
Summer Only
Vacation | Holidays
VPK Wrap Around
Weekend

Type of Care Requested:

Childcare Center
Family Childcare Home
Head Start
Large Family Childcare Home
Military
Nanny | Au Pair
Playgroup
School Age
Summer Camp
VPK School Year
VPK Summer

Child's Special Needs If Applicable

ADHD / ADD
Allergies (severe)
Asthma (severe)
Autism Spectrum Disorders
Cystic Fibrosis
Developmental Delay
Diabetes
Hearing Impairment
Medically Challenged
Mental Disability / Delay
Other List:
Physical Disability / Delay
Seizure Disorder
Speech / Language Delay
Visual Impairment

Comments

“There are no charges/fees associated with a provider listing in the Childcare Resource & Referral Database or for referrals to your program. If you are asked to provide a payment for a referral or listing in the Childcare Resource & Referral database, please call the Agency for Workforce Innovation’s Office of Early Learning at 1-866-357-3239. The information reported about a provider’s program is objective program information that is based on standards that are attainable for providers based on their type of care.”