Child Care Assistance Request Form

Child Care Assistance Request Form

Do you need assistance in your child care center or family child care home? We can help! Please fill out the information below and one of our child care consultants will contact you.

First Name

Last Name

Phone

Email

Place of Employment

Setting:

Child Care CenterOut-of-School Time ProgramFamily Child Care HomeOther

Ages you work with (check all that apply):

InfantsToddlersPreschoolSchool-Age

Technical Assistance Topics:

Room Arrangement	Lesson Planning
Behavior & Guidance	Hand Washing/Diapering
Emergency Preparedness	Spanish/Espanol
Playground Inspection	Process Art
Math	Science
Dramatic Play	Block Play
Literacy	Music & Movement
Sand & Water Play	STARS
Accreditation	Other

If other, please indicate:

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Contact Information