Child Care Inquiry Form
For parents or guardians to inquire about child care services. Complete the form using the PDF-sourced fields in a clean standard layout optimized for web and mobile.
Inquiry Details
Today's Date
*
-
Month
-
Day
Year
Date
Requested start date
*
-
Month
-
Day
Year
Date
What hours do you need child care?
*
Days needed
*
Mondays
Tuesdays
Wednesdays
Thursdays
Fridays
Type of day
*
Full day
Part day
School-age only
Before school
After school
Child 1 Information
Name
*
Gender
*
Please Select
M
F
Date of birth
*
-
Month
-
Day
Year
Date
Age
Grade
School
Child 2 Information
Name
Gender
Please Select
M
F
Date of birth
-
Month
-
Day
Year
Date
Age
Grade
School
Child 3 Information
Name
Gender
Please Select
M
F
Date of birth
-
Month
-
Day
Year
Date
Age
Grade
School
Parent/Guardian and Referral Information
Parent/Guardian Name
*
First Name
Middle Name
Last Name
Cell Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Will you apply for Assistance? 4-C
Yes
No
Currently Approved
How did you learn about CLC?
Submit
Today’s date
*
-
Month
-
Day
Year
Date
Should be Empty: