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Child Care Referrals: Referral Request Form
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* Indicates required question
Parent/Guardian First Name
*
Your answer
Parent/Guardian Last Name
*
Your answer
Relationship to child needing care
*
Your answer
Email Address
*
Your answer
Street Address
*
Your answer
City, State, Zip Code
*
Your answer
If you want child care at another location (employment, school, etc.), enter other location here.
Your answer
Reason for needing child care:
Choose
Employed
In School/Training
Looking for Work
Back up Care
Other Parental Needs
Mildly Ill
Child Protective Services
COVID-19
Enrichment
Daytime phone
*
Your answer
Who will pay for the child care?
Choose
Parent/Guardian
CalWorks
GoKids
Foster Bridge
Other
Birth dates of children needing child care (month/day/year)
Your answer
Start date child care is needed
MM
/
DD
/
YYYY
Days of the week child(ren) need care (Check all that apply)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Child(ren) need care: start time
Time
:
AM
PM
Child(ren) need care: end time
Time
:
AM
PM
Does your child need transportation to/from school?
Your answer
School Name
Your answer
Type of child care preferred
Choose
Child care center
Family child care home
No preference
Comments
Your answer
The Child Development Resource Center provides referrals only - NOT recommendations. It is the parents responsibility to screen potential providers.
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