MCRDC - Child Care Request Form

1. Please enter your personal contact information:

2. For how many children are you seeking child care?

3. Child Information:

Child #1 Information
First Name			Last

Birthdate	Age

Date Care Needed

Preferred Type of Care (select all that apply):
	Child Care Center		In-Home Care
	Family Care Provider		Camp
	Nursery/PreSchool		Occasional Care
	School-Age Care

Details:
Location Desired
Hours Needed
Days Needed	Sunday	Thursday
	Monday	Friday
	Tuesday	Saturday
	Wednesday

Do you need child care on the school bus route?			Yes	No
	If so, what school does your child attend?

Additional Requirements/ Special Needs:

Child #2 Information
First Name			Last

Birthdate	Age

Date Care Needed

Preferred Type of Care (select all that apply):
	Child Care Center		In-Home Care
	Family Care Provider		Camp
	Nursery/PreSchool		Occasional Care
	School-Age Care

Details:
Location Desired
Hours Needed
Days Needed	Sunday	Thursday
	Monday	Friday
	Tuesday	Saturday
	Wednesday

Do you need child care on the school bus route?			Yes	No
	If so, what school does your child attend?

Additional Requirements/ Special Needs:

4. Additional information:

How did you hear about us?	Friend/Relative	Family Focus	Social Service Agency
	Employer	CCAP	DHS or ASPIRE
	Phone Book	Child Care Provder/Center	Another RDC
	Poster	Brochure	Voucher Program

Do you think that cost will be a barrier for you? YesNo

Do you have help paying for child care through any programs? YesNo
(ASPIRE/transitional, vouchers, subsidized slot, Head Start, Home Start)

Would you like information and/or an application for help paying for child care? YesNo

Child #3 Information
First Name			Last

Birthdate	Age

Date Care Needed

Preferred Type of Care (select all that apply):
	Child Care Center		In-Home Care
	Family Care Provider		Camp
	Nursery/PreSchool		Occasional Care
	School-Age Care

Details:
Location Desired
Hours Needed
Days Needed	Sunday	Thursday
	Monday	Friday
	Tuesday	Saturday
	Wednesday

Do you need child care on the school bus route?			Yes	No
	If so, what school does your child attend?

Additional Requirements/ Special Needs:

Child #4 Information
First Name			Last

Birthdate	Age

Date Care Needed

Preferred Type of Care (select all that apply):
	Child Care Center		In-Home Care
	Family Care Provider		Camp
	Nursery/PreSchool		Occasional Care
	School-Age Care

Details:
Location Desired
Hours Needed
Days Needed	Sunday	Thursday
	Monday	Friday
	Tuesday	Saturday
	Wednesday

Do you need child care on the school bus route?			Yes	No
	If so, what school does your child attend?

Additional Requirements/ Special Needs:

MCRDC Child Care Request Form