Find Child Care: Request Form

First Name:

Last Name:

Relationship to Child(ren):

Address:

Apt.#:

City:

State:

Zip:

Daytime Phone:

Alternate Daytime Phone:

Email:

Fax:

Preferred method of contact:

Employer:

Spouse's Employer:

Have you used this service before:

Marital Status:

Married

Single Parent

Do you think you may be eligible for
subsidy from Nassau County Department
of Social Servcies (NC DSS):

(For info regarding eligibility click here)

Number of Children in need of child care:

(If more than 2 just fill out info for first 2 children
and a Parent Counselor will call for further info)

Child 1

Name (optional):

Age:

Date of Birth:

Days Care Needed:

Hours Care Needed:

Date Care Needed:

Elementary School: (either the one that your child currently attends or will attend at the appropriate age)

Desired Location of Care: (where you would prefer the child care program be located - list zip code(s) or town(s); please
limit to 3 or 4)

Type of Care: (For description of Types of Care, click here)
(check as many as apply)

Additional comments:


	How did you hear about us? Internet search, Council materials, print ad, news item, etc.