The Committee for Hispanic Children and Families
Child Care 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.

Name (First & Last):
Number of children:
Telephone:
Alternate telephone:
Address (Apartment #, if applicable):
City, State, Zip Code:
E-mail address:
Have you made a previous request:
Best day to contact (Mon - Fri):
Best time to contact (9:00 a.m. - 5:00 p.m.):
What is your family size:
Household Income (optional):

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) of child care you would like to request (all that apply):

Center Based Care
Family / Group Family Day Care Provider
Exempt / Informal Home Provider
Infant
Toddler
Pre-Kindergarten
Nursery School
Head Start
Kindergarten
School Age
Mildly Ill / Sick Care
After-school Program
Vacation / Holiday Program
Day / Overnight Camp
Drop-in
Other - Explain:

If needed, please check the type(s) of Special Services Care you would like to request (all that apply):

Special Care Needs (Developmental / Educational)
Special Medical / Physical Care Need
Special Diet
Transportation
Bilingual - Language:
Sign Language
Wheel Chair Accessible
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 (all that apply):

Evening
Weekend
Rotary Schedule
Overnight

Reasons for care (all that apply) :

Employment / Seeking work

Training education
Current care ending
Dissatisfied with current care
Development / Social needs of child
Personal / Social needs of parent
Other - Explain:

Location of care (all that apply):

Near home / In home
Near parent's work
Near parent's school
Near child's school
Other - Explain:

Zip Code(s) for child care:

How did you hear about us? (all that apply) :

Internet
Child care provider
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 Committee for Hispanic Children and Families, Inc.
110 William Street, Suite 1802, New York, NY 10038
T: (212) 206-1090; F: (212) 206-8093; chcfinc@chcfinc.org
© 2000 The Committee for Hispanic Children and Families, Inc All rights reserved
Please email us for more information


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