Child Care Needs Form

  • Click Save or Submit at the end of this form.

    In order to find the best match for you and your children’s needs, please complete the following information. Referral requests will be processed and disbursed within 1-5 business days depending on the specific requests and referral volume. The information provided is for referral purposes only. Child Care Referral Program does not warrant the information concerning any provider, nor do we license, endorse, or recommend any particular provider. Only you can determine whether the quality of care is appropriate for your child by thorough screenings and visits with the provider prior to care being provided.
  • Contact Information

  • Tell us a little bit about yourself...

  • Tell us a little bit about your children and the care requests you have

    Providing this information helps us to better match you with child care providers.
  • Child's Name Birthdate (mm/dd/yyyy)  
    There are no children.
    Click in 'Add child' and fill out the the fields for each child requiring care. Missing information prohibits us from being able to provide you a list of child cares. If your hours and days are varied, please list all potential days and hours care may be needed. For example, list the earliest time you would ever work and the latest you would ever work.
    Please note this can greatly restrict your options and we will not include it if it hinders the ability to get you a list of child cares.
  • What kind of child care provider would best meet your needs?

    Check all that apply.
    Check all that apply.
    Check all that apply.
  • Just a couple more questions and you're done!

    Answering these questions helps us to tailor our services to the needs of the community and better understand who is currently looking for child care.
    Check all that apply.
  • How would you like your referral list delivered to you?

    Please have my list of matching child care providers:*
    If you will be picking up your referral in person, please allow 2 business days to process or call ahead to be sure it's ready to pick up when you arrive.