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Request Child Care Resource & Referral

Child Care Resource & Referral Request Form

Please note that the interview process takes approximately 20 minutes after which a customized list made specifically for that parent and child can be emailed, mailed, or faxed. During the interview the parent has the opportunity to ask specific questions regarding early care and education options, the scholarship child care application process and how to access other financial assistance for child care needs.


Fields marked with an * are required

Parent / Guardian Information

Primary Parent / Guardian


Spouse


Residence Address


Contact Information


General Information


Optional Information

The state of Florida asks for this information for statistical purposes about people seeking child care such as do they work or are they in school or training. If you would like to help us with providing this information please complete the following fields.

Your Employer's Information


Your Current Enrollment Information


Child Needing Referral


Child #1

Child #2

Child #3

Child #4


When you click the submit button a confirmation email will be sent to the email you provided above, please keep that email for your records.

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