Child Care Council of Nassau

Find Child Care: Request Form

First Name:
Last Name:
Relationship to Child(ren):

Daytime Phone:
Alternate Daytime Phone:
Preferred method of contact:
Spouse's Employer:
Have you used this service before:
Marital Status:
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):
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.