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English Request Form

Fields marked with an * are required

Fill out this quick form and our Referral Specialist will contact you within  1 business day with a free, customized list of programs that fit your family’s needs.

Referral Request Information Form

Child Care Referral Central English (legacy ninja form)
Client’s Name:
Client's Name:
First Name
Last Name
Street Address:
Street Address:
City
State/Province
Zip/Postal
Country
How did you find out about Early Years’ Referral services (check one):

Child Information

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What days of the week do you need care? (check all that apply)

Time care is needed?

From:
To:
Will you need transportation provided for your child to/from school?
Do you need child care near public transportation?
What type of care are you looking for? (check all that apply)
Do you receive assistance paying for care through a child care voucher?
Are you on a waitlist to receive a child care voucher?
If no, would you like to be placed on the Early Years Durham/Orange/UNC Scholarship Wait List?
Do you give consent for Early Years to share your information with partner agencies that also provide financial assistance for child care? (including DSS)

What criteria would you like considered when conducting a child care search?

Type of License (check all that apply):
Does your child have any special needs? Please indicate:

Statistical Information: (This information is used only for reporting purposes for our funders, which helps to keep our services free. Your response is optional.)

Do you speak any language other than English at home?
Annual Income of Household:
How would you like to receive your referrals?
To speak directly with a Referral Specialist you can call 1-855-327-5933.