Child Care Resource & Referral will provide you with a list of child care providers to call and visit.    The list does not rate or recommend providers.    We encourage all parents to check the files for all licensed and registered providers at the Department of Children and Families.  Your referrals will be sent to you, either by mail or e-mail.   Should you have any questions for a Parent Services Specialist, please call (850) 833-9333.

All information received is confidential and will not be sold or given to any third party.   We use Social Security Numbers solely for the purpose of tracking your information without duplication.  You are not required to supply us with that information, if you do not wish to.

Fields in red are required.

First Name: Last Name:
Home Address:    
City: State: Zip:
Phone:    
Email: Social Security Number:

Type of care desired     (Check all that apply):

Child Care Center Family Child Care Home Before & After School
Summer Camp Play Group Nanny

Are you looking for care near    (Check all that apply):

Home
Work (Specify Address)
Other (Specify Address)

Reason for change in care

Problem Finding Care:

How Many Adults are in your Household?

Please list the children in need of care below. If you are pregnant and are searching for child care, please enter the child's expected date of birth.

Child #1

First Name: Last Name:
Date of Birth:   Social Security Number:
 
 
Days and Times Care is Needed:
Sunday:     to
Monday:     to
Tuesday:     to
Wednesday:     to
Thursday:     to
Friday:     to
Saturday:      to

Please list any additional comments, needs, or concerns regarding this child:

Child #2

First Name: Last Name:
Date of Birth:   Social Security Number:
 
 
Days and Times Care is Needed:
Sunday:     to
Monday:     to
Tuesday:     to
Wednesday:     to
Thursday:     to
Friday:     to
Saturday:      to

Please list any additional comments, needs, or concerns regarding this child:

Child #3

First Name: Last Name:
Date of Birth:   Social Security Number:
 
 
Days and Times Care is Needed:
Sunday:     to
Monday:     to
Tuesday:     to
Wednesday:     to
Thursday:     to
Friday:     to
Saturday:      to

Please list any additional comments, needs, or concerns regarding this child:

Child #4

First Name: Last Name:
Date of Birth:   Social Security Number:
 
 
Days and Times Care is Needed:
Sunday:     to
Monday:     to
Tuesday:     to
Wednesday:     to
Thursday:     to
Friday:     to
Saturday:      to

Please list any additional comments, needs, or concerns regarding this child:

Child #5

First Name: Last Name:
Date of Birth:   Social Security Number:
 
 
Days and Times Care is Needed:
Sunday:     to
Monday:     to
Tuesday:     to
Wednesday:     to
Thursday:     to
Friday:     to
Saturday:      to

Please list any additional comments, needs, or concerns regarding this child: