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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.