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Child Care Referral Request Form

If you would like assistance locating child care, please fill out this form.

First Name:

Last Name:

Address:

City: 

State:

Zip Code:

Home Phone:

Email:

Location of child care desired, please select town(s). For Worcester please select zip codes. If the town you are looking for is outside of our service delivery area, visit the Department of Early Education and Care website for the Child Care Resource and Referral agency that can service you. For multiple selections hold down the Ctrl key.

 

Child Care Connection has contracts with local companies to provide and enhanced child care service to their employees. Please fill in you and your spouse's employer in order that we can identify if you are eligible for this benefit.

Your place of employment:

Industry Employed By:           

Your spouse's place of employment:

Work Phone:

Fax:

CCC is partially funded through the Department of Early Education and Care, we are required to ask you some statistical information, please answer the following questions:

Have you used our service before? Yes No

What is your family status, please choose one of the following?

What is your family size? 2 3 4 5 6 or more

What is your gross family income annually?

What is the primary language spoken in your home?

What is your ethnicity?

Child #1 First Name:

Date of Birth:

Date Care Needed:

Preferred type of care (select all that apply): 

Child Care Center  Family Child Care  Nursery School  School Age Program  In Home Care  Camp

For school age children, what school do they attend?

Hours for care, drop off and pick up times: 

Days:

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Does your child have any special needs or additional requirements?

Child #2 First Name:

Date of Birth:

Date Care Needed:

Preferred type of care (select all that apply): 

Child Care Center  Family Child Care  Nursery School  School Age Program  In Home Care (Nanny)  Camp

For school age children, what school do they attend?

Hours for care, drop off and pick up times: 

Days:

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Does your child have any special needs or additional requirements?

If you need care for more than two children, please enter the information:

Thank you for taking the time to complete this form. The information collected is confidential and used for referral and demographic purposes only. It will not be shared outside of CCC except for statistical purposes. Please click the Submit button to send us your information. Please let us know how you would like to receive your free referrals within one business day:

U.S. Mail   Email  Fax

The names of programs you receive are referrals, NOT recommendations. Child Care Connection does not guarantee the information provided to us by child care providers and programs and cannot assure the quality of child care provided by names referred to you in this process. It is important for families to consider personal factors and values as well as quality in determining the child care placement that will be best for their child.

To contact an information and referral specialist call 508-757-1503 or parent@cccfscm.org.

 

  
     
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