YMCA Childcare Resource Service

LOOKING FOR CHILD CARE?

Looking for Child Care? >Child Care Request Form

Fill out the child care referral request form to receive referrals by email, fax or telephone. If you have questions regarding child care you may contact the referral line at 1.800.481.2151 or 619.521.3070 (calling from outside San Diego County) and speak to a Child Care Consultant. The Child Care Consultant can provide assistance with questions regarding the types of child care, choosing child care and staffing ratio that can help you with make an informed decision about choosing quality child care.

Contact Information:

First Name

Last Name

Address:

Unit #:

City:

State:

Zip Code:

Home Phone:

Work Phone:

- Ext:

Cell Phone:

Fax:

Email Address:

Location of Care:


Near Home	Address or cross streets:
Near Work/School	Zip: add Zip for Work/School
Near Child's School	School Name:

Child's Information:

First Name	Birthday	Days Care Needed	Drop off Time	Pick up Time

Schedule of Care:

Full-time (30 hours or more)	Part-time (30 hours or less)	Drop-in Care
Evenings	Overnight	Before/After School

Type of Child Care:

Child Care Center	Family Child Care Home	Nanny Agencies
Day Camps

Special Needs:

Adaptive Equipment	Cognitive Disability
Communication/Language Delayed	Developmental Disability (Autism, PDD, Downs)
Emotional/Behavioral Disability	Health/Medical
Learning Disability	Physical Disability
Sensory Disability-Hearing	Sensory Disability-Vision
Other:

Child's Language:

English	Spanish	Chinese
Tagalog	Vietnamese	Korean
Other:

Reasons for seeking Child Care:
(Check all that apply)

Employment/Volunteerism	Looking for Work
School/Training	Enrichment/Development
Mildly Ill Child	Other Parent's Needs :

Family Status:

Single Parent	Teenage Parent	Needs Subsidize Care
Military	Specify Military Branch:
TANF (Temporary Assistance for Needing Families)

Referred by:
(Select only one)

Brochure	Co-Worker
Company newsletter/Article	Conference/Workshop/Meeting
Employer	Fairs & Yellow/White pages
Newspaper Ad	Friend/Relative
Flyer	Poster
School	Professional Referral
United Way Infoline	TV/Radio
YMCA-CRS website	Other:

Would you like to receive a Parent Resource Packet? (If so, check this box)

Would you like to receive your child care referrals by:

Fax

Telephone