Child Care Information Request

Information requested by:*
If Case Work, which organization?
If other, please specify
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email
Referral Information
The first two questions (family size & income) will be used to find out if you are eligible for subsidized child care.
Language Spoken at Home
If Other Language Please Specify
Family Composition*
If other, please specify
Family size
Number of children*
Family Income:
Employment Status
Child/Children Needing Care
Childs Name
Sex
Birthdate
Childs Name
Sex
Birthdate
Childs Name
Sex
Birthdate
Childs Name
Sex
Birthdate
Childs Name
Sex
Birthdate
Childs Name
Sex
Birthdate
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
- Pre-Kindergarten
- Head Start
- Kindergarten
- Special Care Needs (Developmental/Educational)
- After-School Program
- Vacation/Holiday Program
Type of Special Needs Care; Please specify
Choose the zip codes where you need care below
Home Zip Code
Work Zip Code
Other Zip code
How did you hear about us?
Questions or comments
Disclaimer
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. **CHCF fully complies with the Americans with Disabilities Act (ADA) and provides accommodations on request for physical access, communication or other needs that ensure our services, activities and employment are available to the blind and visually impaired, the deaf and hearing impaired, or individuals with other special needs. For assistance, please contact CHCF at (212) 206-1090 or chcfinc@chcfinc.org.*

Child Care Information Request

Referral Information

Child/Children Needing Care

Choose the zip codes where you need care below

Disclaimer