Child Care Resource & Referral

Let’s find out more about you and your family. By filling out and submitting this form, we can provide a customized listing of providers in your area that may meet your needs. You should receive a response within a couple of business days.

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Last Page

Parent / Guardian Information

First Name *
Last Name *
Middle Initial
Date of Birth
First Name
Last Name
Middle Initial
Date of Birth

Residence Address

Street Address
Address Line 2
City *
State
Zip Code
Home Phone *
Work Phone
Email *
How would you like to receive additional information on locating quality child care?
U.S. Mail Address
Fax Number

General Information

Family Size
Care Zone Zip Code #1 *
Care Zone Zip Code #2 *
Care Zone Zip Code #3 *
Care Zone Zip Code #4
Care Zone Zip Code #5
Reason for Care *
Household
Referred By *
Problem Finding Care *
Relationship to Child *

Optional Information

The state of Florida asks for this information for statistical purposes about people seeking child care such as do they work or are they in school or training. If you would like to help us with providing this information please complete the following fields.

Your Employer's Information

Employer Name
Phone Number
Street Address
Address Line 2
City
State
Zip Code

Your Current Enrollment Information

Facility Where Enrolled
Facility Phone
Street Address
Address Line 2
City
State
Zip Code

Children Needing Referral

Child #1
You must enter information for at least one child.

First Name *
Last Name *
Date of Birth *
Gender
Child's School (If School Age)
Need Transportation TO School
Need Transportation FROM School
Hours of Care Needed FROM *
Hours of Care Needed TO *
Days Care is Needed *
Desired Program Type
Desired Schedule
Preferred Curriculum
If "Other"
Preferred Environment
If "Other"
Preferred Program Enhancements
Special Needs
Add Second Child?
First Name *
Last Name *
Date of Birth *
Gender
Child's School (If School Age)
Need Transportation TO School
Need Transportation FROM School
Hours of Care Needed FROM
Hours of Care Needed TO
Days Care is Needed
Desired Program Type
Desired Schedule
Preferred Curriculum
If "Other"
Preferred Environment
If "Other"
Preferred Program Enhancements
Special Needs
Would you like to receive more information on financial assistance options? *
Would you like more information on Consumer Education? *
Would you like more information about other community resources? *