Welcome to Child Care Connection

Email a Child Care Specialist...

Please complete the form below and we'll send you a reply regarding available childcare providers.

Please note: We ask only the questions we need so that we can provide you with the best options. No personal information will be shared with other agencies.

All information shared with Child Care Connection shall remain confidential. Child Care Connection does not endorse, rate, recommend or evaluate child care resources, programs, or providers and therefore, Child Care Connection does not assume, warrant, or guarantee quality care. Any information about a caregiver/provider has been provided solely by that caregiver/provider.

Name

Telephone

(include area code, e.g., 000-000-0000)

Street Address

City, State, Zip

County

If you do not live or work in one of these counties, you can find your local Child Care Resource & Referral agency at www.childcareaware.org

Type of care wanted

Which do you prefer care to be nearest:

If other, please specify:

If you are looking for child care near you work please also provide your:
Work Address
Work City		Work Zip
Work County

Age(s) of Children needing care:

Days of week care is needed:

Monday Tuesday Wednesday
Thursday Friday Saturday Sunday

Earliest time you can drop child(ren) off:

Latest time you will pick child(ren) up:

If child is in school, what elementary school do they attend:

Other concerns important to you:

The following questions are optional and are used for statistical purposes only. All information you send will be confidential.
Number of family members in your household:	Adults Children
What is your gross annual income?
How did you hear about Child Care Connection?
Are you receiving child care subsidy?	Yes No
What is the age of the parent of the child(ren)?