Child Care Referral Form

Name: *

Address1: *

City: *

Phone number: *

Email address: *

City where care is needed:
Preference #1: Arroyo Grande Atascadero Cambria Cayucos Creston Grover Beach Los Osos Morro Bay Nipomo Oceano Paso Robles Santa Margarita San Luis Obispo Templeton .....Other *

Days care is needed: *
M T W Th F S S

Hours care is needed: From what time to what time?
until *

Information about your child/children:

Age:	Gender:	Care specifications if different from above.
Year: Month: *	Male Female
Year: Month:	Male Female
Year: Month:	Male Female
Year: Month:	Male Female
Year: Month:	Male Female

(For age, enter 3 years and 2 months if your child turned 3 two months ago.)

Are you receiving subsidized child care?
Yes
No
No, but I would like information about subsidized child care.

What language would you like the provider to speak? *
English
Spanish
Other (please specify)

Why is child care needed? *
Employed
In School/Training
Enrichment or Development
Other parental needs
Looking for work
Alternate/Back-up care

Do you want care: *
near home
near work/school
near child’s school

Are you looking for: *
a child care center
a family child care home

Do you need any off-hour care?
evenings
overnights
weekends
need transportation

Notes: (optional, limited to 1000 characters)

* denotes required field