Request A Child Care Search | Action for Children

Have you ever used our child care referral services before?*

Yes
No

Were you referred to Action for Children by another organization?*

Yes
No

If so, please provide the name of the referring organization.*

Parent Name:*

First Last

Street Address:*

City:*

Zip Code:*

County:*

Search for Care from Home Address?*

Yes
No

If no, provide alternate address:*

Phone Number:*

Email:*

Are you TANF Eligible? (WIC, Medical, SNAP, Cash)*

WIC
Medical
SNAP
Cash
Publicly Funded Child Care (PFCC)
No Benefits

Last Four Digits of Social Security Number:

Parent Date of Birth:

Employed?

Yes
No
Student

If YES, what is your Monthly Income?

Race:

Primary language spoken

Are you currently experiencing homelessness?

Yes
No

Children Who Need Care

Child 1

Child's Date of Birth 1:*

If School Age, School Child Attends 1:

Does your child have Special Needs?

Yes
No

If Yes*

Developmental
Medical

Child 2

Child's Date of Birth 2:

If School Age, School Child Attends 2:

Does your child have Special Needs?

Yes
No

If Yes:*

Developmental
Medical

Child 3

Child's Date of Birth 3:

If School Age, School Child Attends 3:

Does your child have Special Needs?

Yes
No

If Yes:*

Developmental
Medical

Child 4

Child's Date of Birth 4:

If School Age, School Child Attends 4:

Does your child have Special Needs?

Yes
No

If Yes:*

Developmental
Medical

Child 5

Child's Date of Birth 5:

If School Age, School Child Attends 5:

Does your child have Special Needs?

Yes
No

If Yes:*

Developmental
Medical

Days/Time Care is Needed

Please indicate your desired child care start date.*

Check each day needing care:*

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Drop-Off Time:*

:

(Please specify AM or PM)

Pick-Up Time:*

:

(Please specify AM or PM)

If schedule varies, please explain:

Is transportation needed before and/or after school?*

Yes
No

If yes, what school?

Type of child care desired (select all that apply)*

Child Care Center
Family Child Care (Home Provider)
Preschool
School-Age Program

Anything else we need to know?

Send results via:*

Email (most common)
U.S. Mail (choosing U.S. mail will add 5-7 days to receipt of referral)

In 2-3 weeks, we will reach back out to you with some simple questions about our service. Would you prefer a phone call or a text message with a link to our survey?*

Phone Call
Text Message

*This field is required.

All the information you share with us today is confidential, our service is free, and it will only take a few minutes.

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Phone

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