Child Advocacy 4C of Central Michigan - Child Care Referral Request Form

Need Child Care?

Please Call: 989-463-1422 or 800-552-4489 for a Child Care Referral or Complete the form below!

First Name
Last Name
Address
Address 2
City
State
Zip Code
Home Phone	please include area code
Work Phone
Fax Number
E-Mail
County of Residence
County Care Needed In
City or School District Care Need In
How would you like to receive this referral?	MAIL FAX E-Mail

Are you expecting?	YES NO
If yes, what is your due date?	(mm/dd/yyyy)
How many children do you need the child care for?
Please List their DOBs
Child #1	(mm/dd/yyyy)
Child #2	(mm/dd/yyyy)
Child #3	(mm/dd/yyyy)
Child #4	(mm/dd/yyyy)
Child #5	(mm/dd/yyyy)
Child #6	(mm/dd/yyyy)

Do any of the children above have any special needs? (Asthma, Allergies, ADD, ADHD, etc.)	YES NO
If yes, please tell us which child (#) and what needs the child has.
Are you eligible for child care assistance from DHS?	YES NO
Are you a Single or Two-Parent Family	Single Parent Family Two Parent Family
If two parent, please list the other parent if living in the home with you and the child(ren).

Please tell us the type of child care you are searching for (check all that apply):
Full Time
Part Time
Full Year
School Year Only
Summer Only
1st Shift Care Traditional Care Hours (6am-6pm)
2nd Shift Care (evening care after 6pm)
3rd Shift Care (overnight care)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Time Care needed	(ex: 8am-5pm, 2pm-11pm)
Before and/or After School Care
Infant/Toddler Care (care for children 0-30mths.)
Drop-IN Care
Emergency Care
Migrant Care (seasonal care for migrant families)
Respite Care (care for a disabled child to give the caregiver a break)

Please select the types of caregivers you are looking for:	There are 3 types of licensed child care providers
Family Home Licensed to watch up to 6 children
Group Home Licensed to watch up to 12 children with 2 caregivers present
Child Care Centers Licensed to watch 12 children or more
Questions or comments concerning the referral?

The information below is what normally comes in a mailed child care referral, if you are requesting a child care referral via e-mail, this information will not accompany it. Please view & print the information below as needed.

Parent Letter/Disclaimer

Child Care Select® Symbols & Questions

4 Steps to Choosing Quality Child Care

Child Care Licensing Brochure

Serving Clare, Gladwin, Gratiot and Isabella Counties for over 30 years.