Child Care Request Form : Find Child Care

First Name

Last Name

Preferred Contact Phone Number

E-mail Address

Have you used our services before?

Yes
No

Address

City

State

Zip Code

How many miles away from this address are you willing to travel for care?

Employer (for community relations and reporting purposes only.)

Are you receiving child care assistance through the Department of Social Services. (For eligibility information contact the Rockland County Day Care Unit at 845-364-3797)

Yes
No
Unsure

Is your household income less than:

Child 1

First Name

Child 1

Male
Female
Non-Binary
No Information
Expecting

Child 1: Date of Birth

If expecting, enter anticipated due date

Child 2

First Name

Child 2

Male
Female
Non-Binary
No Information
Expecting

Child 2: Date of Birth

Month

/

Day

/

Year

If expecting, enter anticipated due date

Days Care Needed

Check all that apply

Monday through Friday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Hours Care Needed

List specific hours, ex. 9am-5pm

Date Care Needed

Enter a specific date

Type of Care

Check all that apply

Child Care Center
Family Child Care
Before or After School Care
Nursery School
Camp/Summer Care

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If care is needed for a school age child (age 5 or above), provide the name of the school your child attends.

Questions & Comments

Preferred Response

Additional Details

Find Child Care