Vermont Child Care Referral Form

Vermont Child Care Referral Form
You can use this form to contact a local child care referral specialist about your child care needs. Child care referral specialists will contact you to help you with your child care search, and provide you referrals to local child care programs that may meet your needs. If you would like to contact a referral specialist directly, their information is listed on our website at https://dcf.vermont.gov/contacts/partners/cccsa.
Your name*

First NameLast Name
Your Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Email*
example@example.com
Where do you live?
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How do you prefer to be contacted?

PhoneEmail
Employer (optional)
Are you, or another parent a State of Vermont employee?

YesNo
Are you working with anyone to support your family?

VT DCF Family Services Division Social WorkerReach Up Case ManagerSocial WorkerOther
Where are you looking for child care, preschool or out of school time care? (You can chose more than one option, by holding ctrl key and select)*
Information about your children

This information helps the referral specialist understand your needs
1st child's full name
1st child's date of birth

MonthDayYear
Date
2nd child's full name
2nd child's date of birth

MonthDayYear
Date
3rd child's full name
3rd child's date of birth

MonthDayYear
Date
Information on additional children
What days are you looking for care?

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
Hours care is needed?
Start of care

Hour Minutes

AM/PM Option
Until

Hour Minutes

AM/PM Option
What type of care would you prefer?

Home based careCenter based carePreschool in a schoolAny options
When do you want care to start?

MonthDayYear
Date
Any specialized needs?

Asthma friendlyNo petsOpen to dietary requirementsAllergiesOther
Other information that would be helpful? For example, is there a specific bus route for your children, or are you willing to expand your search to additional towns?
The information you submit will be sent to a referral specialist in your area who will contact you within one to two business days. If you do not receive a call or email within three days please email AHS.DCFCDDCCFAPPayments@vermont.gov
Should be Empty:

Vermont Child Care Referral Form

Information about your children

Hours care is needed?