Child Care Referral Information

I understand that Programs for Parents, Inc. does not endorse or recommend child care providers. The names we give you are referrals. They are based on information supplied by the child care providers themselves about the services they offer.

Do you agree with the application knowing this:
I agree to continue with the application knowing this
I do not agree

Name:

Email:

Address: Apt/Fl:

City: State: Zip code:

Home Phone: Work Phone:
Cell Phone:   

Child Date of Birth (mm/dd/yyyy)
Child 1:
Child 2:
Child 3:

Town child care is needed:

Hours care needed: (ex. 7:00AM-7:00PM)

Type of care
Family Child Care:
Licensed Child Care Centers:
Au Pairs/Nannies:

Referred by:

Reason needing care:
Does your children need any special accommodations?

There is no fee for our referral service. The information you provide us is kept confidential. CCR& R and Programs for Parents are committed to protect the privacy of our callers. The information you provide about yourself is used to document the call, answer questions provide referrals and inform you about our disclaimer. We will not share this information with any outside parties.