Child Care Referrals: Referral Request Form
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Parent/Guardian First Name *
Parent/Guardian Last Name *
Relationship to child needing care *
Email Address *
Street Address *
City, State, Zip Code *
If you want child care at another location (employment, school, etc.), enter other location here.
Reason for needing child care:
Daytime phone *
Who will pay for the child care?
Birth dates of children needing child care (month/day/year)
Start date child care is needed
MM
/
DD
/
YYYY
Days of the week child(ren) need care (Check all that apply)
Child(ren) need care:  start time
Time
:
Child(ren) need care: end time
Time
:
Does your child need transportation to/from school?
School Name
Type of child care preferred
Comments
The Child Development Resource Center provides referrals only - NOT recommendations. It is the parents responsibility to screen potential providers.
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