Request A Child Care Search | Action for Children

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
No Benefits

Do You Qualify for Publicly Funded Child Care?*

Yes
No

Last Four Digits of Social Security Number:

Parent Date of Birth:

Employed?

Yes
No
Student

If YES, what is your Monthly Income?

Race:*

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

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
U.S. Mail

If you are in need of interpreter services, please indicate what your primary language is and one of our Family Engagement Specialist will call you with an interpreter on the line to complete your request for a child care search.

Requested Language:

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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