Child Care Network of the Cape & Islands

Online Referral Form

Please complete the following form and click on "Submit" at the bottom of the page. If you do not provide an e-mail address the referrals will be mailed to you.

The information you provide here is confidential and used for referral and demographic purposes only.

First Name:		Last Name:
Address:		PO Box:

City:

State:

Zip Code:

Home Phone:

Work Phone:

Email:

Child #1

First Name:
Date of Birth:
Date Care Needed:

Preferred type of care (select all that apply):
Child Care Center	Family Child Care	Nursery School/Preschool
School Age Program	Camp

In type of care, if you have selected family child care...
Do you want a smoke-free home?	Yes No
Do you want a cat-free home?	Yes No
Do you want a dog-free home?	Yes No
For school age children, what school do they attend?
Hours for care, drop off and pick up times:

Days care is needed:
Monday	Tuesday	Wednesday

Thursday

Friday

Saturday

Sunday

Does your child have any medical concerns or special needs?

Location of child care desired, please list town(s).
1st Choice
2nd Choice
3rd Choice

Child #2

First Name:
Date of Birth:
Date Care Needed:

Preferred type of care (select all that apply):
Child Care Center	Family Child Care	Nursery School/Preschool
School Age Program	Camp

In type of care, if you have selected family child care...
Do you want a smoke-free home?	Yes No
Do you want a cat-free home?	Yes No
Do you want a dog-free home?	Yes No
For school age children, what school do they attend?
Hours for care, drop off and pick up times:

Days care is needed:
Monday	Tuesday	Wednesday

Thursday

Friday

Saturday

Sunday

Does your child have any medical concerns or special needs?

Location of child care desired, please list town(s).
1st Choice
2nd Choice
3rd Choice

We ask some questions for statistical purposes only.

How did you hear about us?
Word of Mouth	Previous User	Child Care Provider
Web Search	EEC	Community Agency
Other:

Reason for seeking child care:
Employment	Relocation	Dissatisfied with Current Provider
	End of Maternity Leave	Other:

Industry employed by?
What is your family size?
What is the primary language spoken in your home?
What is your gross family income annually?

Do you receive tuition assistance for child care through a state-funded voucher?
Yes No

If you have questions or would like more information about tuition assistance, please contact our office and speak with a parent counselor at 508-778-9470, or toll-free 888-530-2430.

Please remember, Child Care Network does not offer recommendations, the profiles you will receive on licensed and legally operating child care programs are informational only. Contact EEC at 508-828-5025, for a compliance history on licensed providers.