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The Committee for Hispanic Children and Families Child Care Provider/Program
Information Request Form
 
To request child care information or submit a question regarding child care to The Committee for Hispanic Children and Families, please complete this form and click "submit". If you prefer, you can call our Parent Counselors at (212) 206-1090.

 

Contact Information (all fields are required)
 
Name (First & Last):  
Number of children:  
Telephone:  
Alternate Telephone:  
Address (Apartment #, if applicable)  
City, State, Zip Code  
Email Address  
Best weekday and time to contact
you (9:00 a.m. -5:00 p.m.)		  
   
Referral Information
 
Your family status:
 
 
Are you eligible for subsidized child care? Please use the chart below to determine eligibility.
Yes    No
 
Family Size:
2
3
4
5
6
Is your  annual  income less  than: 
$35,292
$41,040
43,548
50,880
$58,212
 
 
Child/Children needing care:
 
Name:
Age:
Date of Birth:
Sex: Female
Male
Days of Care: Monday Tuesday Wednesday
Thursday Friday Saturday
  Sunday  
   
Name:
Age:
Date of Birth:
Sex: Female
Male
Days of Care: Monday Tuesday Wednesday
Thursday Friday Saturday
  Sunday  
   
Name:
Age:
Date of Birth:
Sex: Female
Male
Days of Care: Monday Tuesday Wednesday
Thursday Friday Saturday
  Sunday  
   
 
Please check the type(s) for which you would like information (all that apply):
Center-based Care
Summer Camp
Family/Group Family Child Care Provider
Infant
Toddler
Pre-Kindergarten
Nursery School
Head Start
Kindergarten
School Age
Special Care Needs (Developmental/Educational)
Special Medical/Physical Care Need
Special Diet
Sign Language
After-school Program
Vacation/Holiday Program
Day/Overnight Camp
Drop-in
Bilingual - Language:
Wheel Chair Accessible
Transportation
Other - Explain:
 
 
Schedule of care you would like to request (all that apply):
Full time
Part time
Temporary/Emergency
Summer Vacation/Holiday
Before/After-school
Non-traditional Schedule
Evening
Weekend
Rotary
Overnight
 
 
Zip Code(s) for child care:
 
 
How did you hear about us? (all that apply)
 
Internet Search

What did words did you search for?  
Facebook
311
Child Care Provider/Program
Public Community Agency
Private Community Agency
Employer
Relative/Friend
Television - Station:
Newspaper - Specify:
Phone Book
Local Department of Social Services
Other Child Care Resource & Referral Client
Other-Explain:
 
 
Questions/Comments
 
 

The information you receive regarding child care providers is based on the criteria supplied by you.  While we make every effort to supply you with accurate information, most of this data was supplied by the referenced providers.  The providers listed in the information you receive are referrals, not recommendations.  You should always visit providers before deciding on child care. 

 


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The Committee for Hispanic Children and Families, Inc.
110 William Street, Suite 1802 New York, New York 10038
T: (212) 206-1090; F: (212) 206-8093; chcfinc@chcfinc.org

© 2010 The Committee for Hispanic Children and Families, Inc All rights reserved
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