Community Care Application
Please complete all sections below. Your information is kept strictly confidential. For questions, contact Sierra Richards-Peterson at PetersonFamilyServices2026@gmail.com 
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Part A – Applicant Information *
Name:
Date of Birth:
Address:
City,State,Zip:
Phone Number:
Email:
What Services are you Requesting *
Childcare, Caregiving, or Both?
If Requesting Childcare *
Please list number of children and ages.
If Requesting Caregiving *
Please Briefly describe the assistance needed
How often would you need care? *
One- time ,Weekly, Bi-weekly , Multiple days of the month?
What Days would you topically need support? *
What budget were realistic benefit you're family? *
Under $25, $25‐50, $50-100 or $100+
Preferred Contact Method *
Required
Are you primary caregiver? *
Required
If No, what is your relationship to the care recipient? *
Start Date: *
Estimated hours per week: *
Special Instructions or Care Notes: *
How did you hear about us?
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