Name:
Address:
City:  State:
Zip: County:

Home Phone Number: (please include area code)
Other Phone Number: (please include area code)
E-mail address: (if you wish referral information by e-mail)

If you are relocating to the area or would like for us to pull a search near another location, please include all known information below.  Referrals will only be mailed to the above address, or sent to the destination you have requested.

Address:
City:  State:
Zip:
County: Crisp Dooly Macon Randolph Schley Sumter Taylor Webster

Child Information

Child's first name:    Date of Birth:
Child's first name:    Date of Birth:
Child's first name:    Date of Birth:
Child's first name:    Date of Birth:
Child's first name:    Date of Birth:

When do you need child care to begin? (enter date)

If transportation is needed from child's school, give school name:

What program(s) are you interested in? (check all that apply)
Family Child Care Child Care Center Head Start Program Lottery Funded Pre-K Nanny Service Mother's Morning Out Other

Day care is needed: Monday   Tuesday   Wednesday   Thursday   Friday   Saturday   Sunday  (check all that apply)

Hours needed: to
(include am and pm designations)

Special needs (i.e., allergies, asthma, cerebral palsy, etc.)

Reason for seeking child care: work looking for work end of leave attending school care center closing asked to leave unhappy with quality of current care expense other

How do you wish to be contacted?
  phone postal mail e-mail fax Fax Number:   

The following is for statistical purposes and will not be used for any reason other than to advocate for child care and family services.

How did you hear about our services? Internet friend family member another provider DFCS poster other

Your age range:  20 or younger 21 - 26 27 - 32 33 - 39 40 - 45 46 - 50 51 or older   

Average family income range: under $25,000 25,000 to 34,999 35,000 to 39,999 40,000 to 44,999 45,000 to 59,999 60,000 and over

Relationship to children needing care:  mother father grandparent guardian other   

Household caregivers: 
  one parent two parents parent/guardian   Language spoken at home:

Additional comments: