Community Action Partnership of Madera County

Community Action Partnership of Madera County
“Finding Quality Care”


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Child Care Referral Request

If you wish to request a child care referral for Madera County, please complete this form. Click on the submit button to email the form to us or print and fax it to:

CAPMC Child Care Resource and Referral
Fax Number: (559) 675-1497

School nearest your home:
Name:
Address:
City:
State:
Zip code:
Phone number:
Children's ages:
1st Child:     2nd Child:     3rd Child:     4th Child:
Requested child care days:
 (check all that apply)
Mon-Fri
Mon    Tues    Wed    Thurs    Fri    Sat    Sun
Earliest expected drop-off time: AM / PM
Latest pick-up time:
 		AM / PM
Specific child care wanted:
 (check all that apply)
Center    Family day care home    Drop-in care needed
Where would you like child care:
 (check all that apply)
Near home Cross streets:
Near parent's work/school/training Cross streets:
Near child's school Name of school:
Reason why you need child care:
 (check all that apply)
Employment Other parent needs School/Training
Enrichment Looking for work Alternative/backup care
CPS    
Language of service preferred:
 English    Spanish    Other
Any special need or request:

How did you want to receive this referral:
Mailed
Email
Fax
Comments:


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