Please provide the following contact information: (*Required Fields)

First Name*
Last Name*
Home Phone*
Work Phone
Fax
E-mail

Which city would you like child care in (select all that apply).
To select more than one option hold your "CTRL" key and left mouse click each option to select.

Are you a Subsidy or CalWORKS client:

Do you need care near:

Based on the previous question, please provide the address, city, zip code and major cross streets: (*Required Fields)

Address*
City*
Zip Code*
Cross Streets*  &


Please enter all information regarding your child:

Name or initials:
Date of birth*: MM/DD/YY
Enter the date that you would like to begin care*:
Will the child be in kindergarten when they need care?*
Hours that care is needed: (0:00am - 0:00pm)*:
Please indicate which day(s) care is needed*:
Schedule of care requested:
Week Schedule:
Day Schedule:

Type of care (Please select all types of care you will consider).
To select more than one option hold your "CTRL" key and left mouse click each option to select.

Please provide additional information if "Other" is selected from above under Types of Care?

Does your child have special needs:
Do you need the provider to provide transportation to and from school:
If yes, which school does the child need transportation to:
Do you use public transportation:
Do you prefer a provider that is walking distance to your child's school:


Do you have a second child?

Please enter all information regarding your Second child if applicable:

Name or initials:
Date of birth*: MM/DD/YY
Enter the date that you would like to begin care*:
Will the child be in kindergarten when they need care?*
Hours that care is needed: (0:00am - 0:00pm)*:
Please indicate which day(s) care is needed*:
Schedule of care requested:
Week Schedule:
Day Schedule:

Type of care (Please select all types of care you will consider).
To select more than one option hold your "CTRL" key and left mouse click each option to select.

Please provide additional information if "Other" is selected from above under Types of Care?

Does your child have special needs:
Do you need the provider to provide transportation to and from school:
If yes, which school does the child need transportation to:
Do you use public transportation:
Do you prefer a provider that is walking distance to your child's school:


Please enter your relationship to the child:
Who referred you to our agency website:


Do you have any specific information about providers that you would like included in your referrals. (i.e., meals, education, training, pets, curriculum)

Statistical Information (Optional):
The following information assists SNCS with reporting to our funding sources. SNCS does not disclose the names of clients or their children. This is information is confidential.

Your employment status:
Please enter your family size (include parents and children)
Are you single head of household:
Please provide your Race/Ethnicity:

 
   
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