Parent/Guardian Information
First Name
Last Name
Phone Number
Email Address
In which language do you prefer to communicate?
Please select...
English
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Chinese
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Greek
Gujarati
Haitian Creole
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Igbo
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Italian
Japanese
Korean
Malayalam
Myanmar (Burmese)
Pashto
Polis
Portuguese
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Russian
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Swedish
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Vietnamese
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Street Address
City
State
ZIP
County
Please select...
Adams
Allen
Bartholomew
Benton
Blackford
Boone
Brown
Carroll
Cass
Clark
Clay
Clinton
Crawford
Daviess
Dearborn
Decatur
Dekalb
Delaware
Dubois
Elkhart
Fayette
Floyd
Fountain
Franklin
Fulton
Gibson
Grant
Greene
Hamilton
Hancock
Harrison
Hendricks
Henry
Howard
Huntington
Jackson
Jasper
Jay
Jefferson
Jennings
Johnson
Knox
Kosciusko
LaGrange
Lake
LaPorte
Lawrence
Madison
Marion
Marshall
Martin
Miami
Monroe
Montgomery
Morgan
Newton
Noble
Ohio
Orange
Owen
Parke
Perry
Pike
Porter
Posey
Pulaski
Putnam
Randolph
Ripley
Rush
Scott
Shelby
Spencer
St. Joseph
Starke
Stueben
Sullivan
Switzerland
Tippecanoe
Tipton
Union
Vanderburgh
Vermillion
Vigo
Wabash
Warren
Warrick
Washington
Wayne
Wells
White
Whitley
Spanish to SDA 1
Spanish to SDA 3
Spanish to 211
Preferred Contact Method
Please select...
Email
Phone
Preferred Contact Method
Please select...
Email
Phone
Text
Tell us about your family's current needs.
Are you looking for a child care program?
Yes
No
Goes to CCRR
What type of care are you looking for? (select all that apply)
I am expecting a baby and looking for infant care
I am looking for care for my infant(s) (0-12 months)
I am looking for care for my toddler(s) (13-36 months)
I am looking for care for my preschooler(s) (3-5 years)
I am looking for care for before- and afterschool care and/or summer care
I need a child care program who will support my child(ren) with special needs
I am experiencing housing insecurity
What school does your child attend?
Would you like for us to contact child care programs to check current openings for your child(ren) who need care?
Yes
No
We use your address to find a child care close by. Is there an additional address (i.e. work) that you would like us to try?
Yes
No
Street Address
City
State
ZIP
County
Please select...
Adams
Allen
Bartholomew
Benton
Blackford
Boone
Brown
Carroll
Cass
Clark
Clay
Clinton
Crawford
Daviess
Dearborn
Decatur
Dekalb
Delaware
Dubois
Elkhart
Fayette
Floyd
Fountain
Franklin
Fulton
Gibson
Grant
Greene
Hamilton
Hancock
Harrison
Hendricks
Henry
Howard
Huntington
Jackson
Jasper
Jay
Jefferson
Jennings
Johnson
Knox
Kosciusko
LaGrange
Lake
LaPorte
Lawrence
Madison
Marion
Marshall
Martin
Miami
Monroe
Montgomery
Morgan
Newton
Noble
Ohio
Orange
Owen
Parke
Perry
Pike
Porter
Posey
Pulaski
Putnam
Randolph
Ripley
Rush
Scott
Shelby
Spencer
St. Joseph
Starke
Stueben
Sullivan
Switzerland
Tippecanoe
Tipton
Union
Vanderburgh
Vermillion
Vigo
Wabash
Warren
Warrick
Washington
Wayne
Wells
White
Whitley
Tell us about your child(ren) who need care.
Child's First Name
Child's Birth Month
Please select...
January
February
March
April
May
June
July
August
September
October
November
December
Child's Birth Date
Please select...
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Child's Birth Year
Please select...
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
Goes to 211
Goes to CCRR
Which days do you need care?
Select as many as apply
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
What date do you need to start care?
Month
Please select...
January
February
March
April
May
June
July
August
September
October
November
December
Day
Please select...
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Please select...
2022
2023
2024
2025
2026
What time will you plan to drop off your child?
Please select...
1:00
2:00
3:00
4:00
5:00
6:00
7:00
8:00
9:00
10:00
11:00
12:00
Select One:
Please select...
AM
PM
What time will you plan to pick up your child?
Please select...
1:00
2:00
3:00
4:00
5:00
6:00
7:00
8:00
9:00
10:00
11:00
12:00
Select One:
Please select...
AM
PM
What else is important for us to know about your needs/preferences regarding child care? For example, you can share details about your child's special needs, transportation needs, your preferences about the type of care you would like or any concerns you have.
Do you have another child that needs care?
Yes
No
Do you want to copy the date, days and times for care for all children?
Yes
No
Tell us about your child(ren) who need care.
Child's First Name
Child's Birth Month
Please select...
January
February
March
April
May
June
July
August
September
October
November
December
Child's Birth Date
Please select...
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Child's Birth Year
Please select...
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
Which days do you need care?
Select as many as apply
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
What date do you need to start care?
Month
Please select...
January
February
March
April
May
June
July
August
September
October
November
December
Day
Please select...
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Please select...
2022
2023
2024
2025
2026
What time will you plan to drop off your child?
Please select...
1:00
2:00
3:00
4:00
5:00
6:00
7:00
8:00
9:00
10:00
11:00
12:00
Select One:
Please select...
AM
PM
What time will you plan to pick up your child?
Please select...
1:00
2:00
3:00
4:00
5:00
6:00
7:00
8:00
9:00
10:00
11:00
12:00
Select One:
Please select...
AM
PM
Which days do you need care?
Select as many as apply
What date do you need to start care?
Month
Day
Year
What time will you plan to drop off your child?
Select One:
What time will you plan to pick up your child?
Select One:
What else is important for us to know about your needs/preferences regarding child care? For example, you can share details about your child's special needs, transportation needs, your preferences about the type of care you would like or any concerns you have.
Do you have another child that needs care?
Yes
No
Tell us about your child(ren) who need care.
Child's First Name
Child's Birth Month
Please select...
January
February
March
April
May
June
July
August
September
October
November
December
Child's Birth Date
Please select...
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Child's Birth Year
Please select...
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
Which days do you need care?
Select as many as apply
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
What date do you need to start care?
Month
Please select...
January
February
March
April
May
June
July
August
September
October
November
December
Day
Please select...
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Please select...
2022
2023
2024
2025
2026
What time will you plan to drop off your child?
Please select...
1:00
2:00
3:00
4:00
5:00
6:00
7:00
8:00
9:00
10:00
11:00
12:00
Select One:
Please select...
AM
PM
What time will you plan to pick up your child?
Please select...
1:00
2:00
3:00
4:00
5:00
6:00
7:00
8:00
9:00
10:00
11:00
12:00
Select One:
Please select...
AM
PM
Which days do you need care?
Select as many as apply
What date do you need to start care?
Month
Day
Year
What time will you plan to drop off your child?
Select One:
What time will you plan to pick up your child?
Select One:
What else is important for us to know about your needs/preferences regarding child care? For example, you can share details about your child's special needs, transportation needs, your preferences about the type of care you would like or any concerns you have.
Do you have another child that needs care?
Yes
No
Tell us about your child(ren) who need care.
Child's First Name
Child's Birth Month
Please select...
January
February
March
April
May
June
July
August
September
October
November
December
Child's Birth Date
Please select...
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Child's Birth Year
Please select...
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
Which days do you need care?
Select as many as apply
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
What date do you need to start care?
Month
Please select...
January
February
March
April
May
June
July
August
September
October
November
December
Day
Please select...
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Please select...
2022
2023
2024
2025
2026
What time will you plan to drop off your child?
Please select...
1:00
2:00
3:00
4:00
5:00
6:00
7:00
8:00
9:00
10:00
11:00
12:00
Select One:
Please select...
AM
PM
What time will you plan to pick up your child?
Please select...
1:00
2:00
3:00
4:00
5:00
6:00
7:00
8:00
9:00
10:00
11:00
12:00
Select One:
Please select...
AM
PM
Which days do you need care?
Select as many as apply
What date do you need to start care?
Month
Day
Year
What time will you plan to drop off your child?
Select One:
What time will you plan to pick up your child?
Select One:
What else is important for us to know about your needs/preferences regarding child care? For example, you can share details about your child's special needs, transportation needs, your preferences about the type of care you would like or any concerns you have.
Do you have another child that needs care?
Yes
No
Tell us about your child(ren) who need care.
Child's First Name
Child's Birth Month
Please select...
January
February
March
April
May
June
July
August
September
October
November
December
Child's Birth Date
Please select...
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Child's Birth Year
Please select...
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
Which days do you need care?
Select as many as apply
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
What date do you need to start care?
Month
Please select...
January
February
March
April
May
June
July
August
September
October
November
December
Day
Please select...
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Please select...
2022
2023
2024
2025
2026
What time will you plan to drop off your child?
Please select...
1:00
2:00
3:00
4:00
5:00
6:00
7:00
8:00
9:00
10:00
11:00
12:00
Select One:
Please select...
AM
PM
What time will you plan to pick up your child?
Please select...
1:00
2:00
3:00
4:00
5:00
6:00
7:00
8:00
9:00
10:00
11:00
12:00
Select One:
Please select...
AM
PM
Which days do you need care?
Select as many as apply
What date do you need to start care?
Month
Day
Year
What time will you plan to drop off your child?
Select One:
What time will you plan to pick up your child?
Select One:
What else is important for us to know about your needs/preferences regarding child care? For example, you can share details about your child's special needs, transportation needs, your preferences about the type of care you would like or any concerns you have.
Do you have another child that needs care?
Yes
No
Tell us about your child(ren) who need care.
Child's First Name
Child's Birth Month
Please select...
January
February
March
April
May
June
July
August
September
October
November
December
Child's Birth Date
Please select...
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Child's Birth Year
Please select...
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
Which days do you need care?
Select as many as apply
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
What date do you need to start care?
Month
Please select...
January
February
March
April
May
June
July
August
September
October
November
December
Day
Please select...
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Please select...
2022
2023
2024
2025
2026
What time will you plan to drop off your child?
Please select...
1:00
2:00
3:00
4:00
5:00
6:00
7:00
8:00
9:00
10:00
11:00
12:00
Select One:
Please select...
AM
PM
What time will you plan to pick up your child?
Please select...
1:00
2:00
3:00
4:00
5:00
6:00
7:00
8:00
9:00
10:00
11:00
12:00
Select One:
Please select...
AM
PM
Which days do you need care?
Select as many as apply
What date do you need to start care?
Month
Day
Year
What time will you plan to drop off your child?
Select One:
What time will you plan to pick up your child?
Select One:
What else is important for us to know about your needs/preferences regarding child care? For example, you can share details about your child's special needs, transportation needs, your preferences about the type of care you would like or any concerns you have.
Do you have another child that needs care?
Yes
No
Tell us about your child(ren) who need care.
Child's First Name
Child's Birth Month
Please select...
January
February
March
April
May
June
July
August
September
October
November
December
Child's Birth Date
Please select...
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Child's Birth Year
Please select...
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
Which days do you need care?
Select as many as apply
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
What date do you need to start care?
Month
Please select...
January
February
March
April
May
June
July
August
September
October
November
December
Day
Please select...
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Please select...
2022
2023
2024
2025
2026
What time will you plan to drop off your child?
Please select...
1:00
2:00
3:00
4:00
5:00
6:00
7:00
8:00
9:00
10:00
11:00
12:00
Select One:
Please select...
AM
PM
What time will you plan to pick up your child?
Please select...
1:00
2:00
3:00
4:00
5:00
6:00
7:00
8:00
9:00
10:00
11:00
12:00
Select One:
Please select...
AM
PM
Which days do you need care?
Select as many as apply
What date do you need to start care?
Month
Day
Year
What time will you plan to drop off your child?
Select One:
What time will you plan to pick up your child?
Select One:
What else is important for us to know about your needs/preferences regarding child care? For example, you can share details about your child's special needs, transportation needs, your preferences about the type of care you would like or any concerns you have.
Tell us about your financial assistance needs.
By sharing your household members and income, we can connect you with opportunities that might be a good fit for your family. What is your family's monthly gross income, also known as income before taxes?
Please select...
I am not interested in income based support
Less than $2,000 per month
$2,000 - $2,999 per month
$3,000 - $4,999 per month
$5,000 - $6,999 per month
$7,000 or more per month
How many members are in your family's household?
Please select...
1
2
3
4
5
6
7
8
9
10
11
12
Programs like CCDF vouchers and On My Way Pre-K help qualifying families afford child care. Would you like more information on financial assistance programs?
Yes
No
I don't know
Is your child(ren) currently enrolled or on a waitlist for a CCDF voucher or On My Way Pre-K?
Yes
No
Additional Resources and Support
How did you hear about us?
Please select...
Friend or family member
Google search
Social media
YouTube
Radio, newspaper or television
Community or family event
Referral from another agency or organization
Employer
CCDF email
Other
Other Agency or Organization:
Your Employer
Please specify:
Would you like to receive newsletters and/or updates about early childhood education from your local CCR&R agency?
Yes
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Do you or someone you know need help connecting to resources related to any of the following topics? Select all that apply.
Please select...
School-Age learning and development
Finding or paying for healthcare
Housing or transportation
Food access
Adult job training
Parenting support
Other
By submitting this referral form you are consenting to a referral specialist using the information you have provided to locate child care options. If you have indicated that your family has additional needs, you are also consenting to your information being provided to findhelp in order to locate resources and community organizations that can support your family.
Can we share these updates with you via text at the number listed above?
Yes
Yes, but I need to provide another number.
No
You can text me updates at the following number.