If you would like assistance locating child care, please fill out this form or contact us at 1-580-548-2285, 1-580-548-2318 or 1-800-401-3463Please note that the fields marked red are required to fully process your request.
Full Name:
Address:
Address Line 2:
City:
State: Oklahoma
Zip:
Daytime Phone (with area code):
Evening Phone (with area code):
Email Address:
Relationship to the child(ren) for whom you need care:
Work Address:
Work Phone Number:
Fax Number(home or work):
Nearest Work Intersection:
Year schedule: Full YearSchool YearSummer
Does your child need transportation? None To and from school To school From school Both to and from school
What other criteria are you looking for in a child care provider? non-smoking environment no pets no preference
Do you have any type of Subsidy? None DHS Sliding Scale SSI Indian Contract
How did you find out about us? search engine personal referral (e.g. friend, co-worker, RR agency) commercial Other
If you need child care for more than two children, please enter the information below:
How do you want the referral specialist to get this information back to you? Fax Email Phone Mail
1st Child's Information
Name of Child:
Birthday:
Age:
Date Care Needed:
Preferred Type of Care (select all that apply):Child Care Center Family Child Care Home Nursery/Preschool School Age Care Montessori Drop-In / Playtime Camp Before & After School Summer Camp Other
Special Schedule: Drop in Hourly temp/emergency Sick Care 24 hour
Where do you want this care located? Near work Close to home Between work and home Near Child's School no preference Other
Hours Needed:
Days: Sunday Monday Tuesday Wednesday Thursday Friday Saturday
Additional requirements/special needs:
2nd Child's Information
Preferred Type of Care (select all that apply): Child Care Center Family Child Care Home Nursery/Preschool School Age Care Montessori Drop-In / Playtime Camp Before & After School Summer Camp Other
Additional requirements/ special needs:
Please complete the following Census Bureau questions: Are you? I choose not to answer Spanish/Hispanic/Latino Mexican/Mexican American, Chicano Puerto Rican Cuban Other - please specify What is your Race? I choose not to answer White African American American Indian/Alaskan Asian Indian Native Hawaiian Chinese Filipino Japanese Vietnamese Other Asian Guamanian or Chamorro Samoan Other Pacific Islander Other Do you speak a language other than English at home? No Yes - please specify
Additional Information About You: Your Age Under 20 years 20-29 years 30-39 Years 40-49 years 50 or over Relationship to Children listed above: Father Mother Grandparent Guardian Relative Foster Parent Other Current Employment Status: Employed Seeking Employment At Home Student TANF Family Income (Yearly): Up to $28,000 Greater than $28,000 I choose not to answer Family Size: Select One Two Three Four Five Six Seven Eight Nine or More Number of Adults in Home: Select One One Adult Two or More Adults
Thank you for taking the time to complete this form.Please enter the code shown below and then click the 'Submit Request Form' to send us your information.
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Describe Yourself: Parent Center Teacher Center Director Family Child Care Provider CCR&R Professional Other
Did you find the information you were looking for on our web site? Yes No
If not, what additional information would you have liked to have seen?
How satisfied were you with our web site? Very Satisfied Somewhat Satisfied Not Satisfied
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Would you recommend our web site to others? Yes No
Overall Comments:
Thank you for taking the time to complete this form.Please enter the code shown below and then click the 'Submit Feedback Form' to send us your information.
Child Care Request Form (Blue Form)Child Care Feedback Form (Green Form)
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