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We offer free, personalized services to help you locate safe, quality child care that meets the needs of your family. Complete this form so we can begin the referral process. We'll be in touch shortly!

If you have more than two children in need of child care, please submit an additional form.

Contact Information

Have you used our services before?

Personalized Referral Infomation

Please enter an address closest to your desired location of care. (i.e., home, employer)

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)
First Name
Child 1
If expecting, enter anticipated due date
First Name
Child 2
/
/
If expecting, enter anticipated due date
Days Care Needed
Check all that apply
List specific hours, ex. 9am-5pm
Enter a specific date
Type of Care
Check all that apply
Additional Details