Parent Request Form for Child Care Referral

Staff of the CCR&R Agency of West Georgia at Columbus will use the information you provide below to generate a free referral for child care. All information is confidential and is required by our funding source. No personal information will be given or sold to any third party.

The response you will receive is intended for referral purposes only. We do not warrant the information concerning any provider, nor do we license, endorse or recommend any particular provider. Only you can determine whether the quality of care is appropriate for your child.

NOTE: You will receive your referral via regular mail to the address you provide below.

Items in red marked with an * are required.

First name: *
Last name: *
Address: *
City: *
State: *
Zip: *
Phone Number: *

E-mail address: *

Retype your e-mail address: *

Number of children for whom you are seeking care: * Newborn (0 to 7 weeks)
Infant (8 weeks to 1 year)
1 year old
2 year old
3 year old
4 year old
5 year old
6 year old
7 year old
8 year old
9 year old
10 year old
11 year old
12 year old

What time do you prefer your child care to begin (i.e. 9:00 a.m.)? *

-- hh:mm am/pm

What time will you pick up your child(ren) from care? *

-- hh:mm am/pm

What days of the week do you need child care? *

Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

In what county do your prefer your child care to be located?

Please give a location you prefer your care to be near (i.e. Near Wynnton Road and Brown Avenue)

Please provide a secondary location for your care (optional).

What type of care are you seeking: *

No preference
Registered Family Child Care Home
Licensed Group Child Care Home
Licensed Child Care Center
Head Start Program
Lottery-funded pre-K Program
Before School Care
After School Care
Before and After School Care

Will you need your school age children transported to and/or from school?

Yes
No

If yes, please specify the name(s) of the school(s).

Please state any additional information that will assist CCR&R Agency staff in providing an accurate referral.

I wish to receive information on possible eligibility for the Child Care Subsidy program monitored by the Department of Family and Children's Services (DFCS):

Yes
No

The Child Care Resource and Referral Agency of West Georgia at Columbus is funded by Bright from the Start, a program of the Georgia Department of Early Care and Learning, through the Federal Child Care Development Grant.


Child Care Resource & Referral Agency of West Georgia at Columbus Jordan Hall, 218 Phone: 706-569-3109 \| 1-800-650-2102	Text-only version Questions/Comments?	Columbus State University 4225 University Avenue Columbus, Georgia 31907