720 S. Elmwood Ave. Suite 4 * Traverse City, MI 49684 * 231-941-7767 * 1-800-968-4228
 

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Request Child Care Referrals

Please fill out this form completely to ensure an accurate listing of day care providers.  We will need to call you if there is any missing information. *Red fields are required. 

Please provide the following contact information:

First Name  
Last Name  
Street Address  
City  
State  
Zip Code  
County of residence  
County care is needed 
Home Phone  
Work Phone
FAX
E-mail
Employer  

If Not Currently Employed please enter N/A

The following income guidelines will help you determine if you qualify for child care assistance through the DHS (please select one):

Family size/income:


Parent status:


Do you need an application for DHS child care assistance?

Yes No

Are you a MiWorks! participant?

Yes No

How did you hear of Child Care Connections?


Reason you are looking for child care:


We do searches for providers who care for your child's age - please enter their date of birth below so we can provide you with an accurate listing.

Child 1 needing care:

Date of Birth

Child 2 needing care (if applicable):

Date of Birth

Child 3 needing care (if applicable):

Date of Birth

Child 4 needing care (if applicable):

Date of Birth

Are you expecting a child?

      Yes  No

If yes, please list the approximate age the child will be when care will be needed?

      

Does your child have any diagnosed special needs?

Yes No

If yes, please give a brief explanation:


Type(s) of child care desired:

Family Home
Group Home
Child Care Center
Pre-school

In which city(ies) or public elementary school area(s) do you prefer care? (Note: If care is needed in Traverse City, please indicate the public elementary school as there are over 200 providers in the TC area).


Days care is needed:

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Times care is needed:


Additional needs or requests:


*Note: If you would like this list emailed to you, please verify that you have entered the correct email address above. 

    

Please remember that Child Care Connections does not recommend, license or endorse any caregiver. The lists of providers are intended as referrals only. Please ask providers if they have vacancies, ask for references and set up interviews.

If you do not receive your list of referrals by email within 2 business days, please contact our office at 231-941-7767. Some email accounts, especially in corporate environments, will not accept attachments. Thank you for your understanding.


Copyright © 2006 [Child Care Connections]. All rights reserved.
Revised: 07/30/08