Child Care Request Form

Child Care Referral Request Form

This request will generate a list of Manatee County child care providers that meet the criteria you enter below.

If you are looking for financial assistance for child care, please research our School Readiness program.

Parent's Last Name *

Parent's First Name *

Street *

City *

State

Zip *

Contact Phone # *

Email Address

Gender

Male Female

Preferred Language

Employer

Relation to Child *

Adults in Household *

Total Number of Persons in Household/ Family Unit *

Reason For Care *

Problem Finding Care *

Referred By

Number of Children:

Child 1

Last Name	Gender	Special Needs

	Male Female	No Yes Please explain:

School (if enrolled) Days Needing Care M Tu W Th F Sa Su From am pm To am pm

Criteria

Please indicate if you have a preference for any of the following criteria.
(Hold CTRL key to select all entries that apply)

Schedule

Program

Environment

Enhanced Services

Special Needs

Transportation Needs

Curriculum

I Would Also Like Information On

Additional Comments

Are you in need of assistance paying for the cost of child care?

Yes No

Are you currently receiving child care funding assistance?

Yes No

Select up to five zip codes in Manatee County where you are looking for child care: *

Please indicate how you wish to receive your referrals and parent packet:

Fax

Mail

Pickup at Early Learning Coalition's office
(Please contact us at 941-757-2900 to confirm completion of your referrals prior to picking up.)

24 Hour Care
After School
Both Full-time and Part-time
Before School
Drop-in Care
Emergency/Temporary Care
Evening Care - after 6:30pm
Full Time
Full Year
Hourly
Morning
Open in Safe Weather
Overnight
Part Time
Respite Care
Rotating
Summer Only
School System Weather Days
School Year
Vacation/Holidays
Weekend Care
VPK Wrap Care

Bilingual
Diapers Provided
Employer Contract
Elevator
Faith Based Center
Fenced Yard
Green Certified Building
Medicaid Provider
Multi-Child Discount
Negotiated Rates
Operation Military Child Care
Outdoor Play
Parent Co-op
Pet Onsite is OK
Pool Onsite is OK
Private School
Provides Meals
Scholarships Available
Sick Child Care
Sign Language
Sliding Fee Scale
Smoke-Free
Teen Parent Program
Video Monitoring
Webcam Onsite
Wheel Chair Accessible
Other

Child Behavior
Child Care Funding Assistance
Child Development
Clothing
Domestic Violence
Drug and/or Alcohol Abuse
Emergency Family Services/211
Employment
Food
Financial Assistance
Health Insurance
Housing
Hurricane/Disaster
Military Subsidy Information
Parent Education/Training information
Parenting Topics
Rent Assistance
Transportation
Utilities Assistance
Voluntary Prekindergarten
Other Referrals

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