Home Parents Child Care Referral Request Form
	Child Care Referral Request Form Contact Information *First Name Middle Initial *Last Name *Mailing Address *City *State *Zip Code Physical Address (If different from mailing address) City State Zip Code *County *Home Phone including area code Cell Phone Work Phone E-mail *Which county would you like care in? Please select ... Edgecombe Nash Halifax Warren Wilson *Do you currently receive subsidy? Yes No Child Information Child's Name *Child's Date of Birth (mm/dd/yy) *Hours care is needed (0:00am-0:00pm) *Days care is needed Depress "Ctrl" key to select multiple days Monday Tuesday Wednesday Thursday Friday *Schedule of Care Please select ... Full Year School Year Summer Care Before School After School Part-Time Child's Race/Ethnic Group Please select ... White/European Black/African Native American/Alaskan Asian Native Hawaiian/Pacific Islander Spanish/Latino/Hispanic Other Household Information Family Size (parents and children only) *Type of Household Please select ... Employed-Single Parent Employed-Two Parent Full-Time Student Disabled Unemployed

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