Parent Referral Form 2 Please complete the form below so we can help you find child care options that best fit your family’s needs. This service is free and confidential. We provide referrals only and cannot recommend specific providers. Results are typically sent within 24 business hours.* Name Name First Name First Name Last Name Last Name Today’s Date Street Address * Address Line 2 City * Zip Code * County * Adair Adams Allamakee Appanoose Audubon Benton Black Hawk Boone Bremer Buchanan Buena Vista Butler Calhoun Carroll Cass Cedar Cerro Gordo Cherokee Chickasaw Clarke Clay Clayton Clinton Crawford Dallas Davis Decatur Delaware Des Moines Dickinson Dubuque Emmet Fayette Floyd Franklin Fremont Greene Grundy Guthrie Hamilton Hancock Hardin Harrison Henry Howard Humboldt Ida Iowa Jackson Jasper Jefferson Johnson Jones Keokuk Kossuth Lee Linn Louisa Lucas Lyon Madison Mahaska Marion Marshall Mills Mitchell Monona Monroe Montgomery Muscatine Osceola Page Palo Alto Plymouth Pocahontas Polk Pottawattamie Poweshiek Ringgold Sac Scott Shelby Sioux Story Tama Taylor Union Van Buren Wapello Warren Washington Wayne Webster Winnebago Winneshiek Woodbury Worth Wright If your address is not in Iowa, or you would like us to search a different location, please list it below: Email * If you do not have an email, please type N/A. Phone Number * May we contact you by phone or text if needed? * Yes No We will only contact you if needed for follow-up questions or to let you know your results are ready. We do not send marketing messages. Number of children needing care * Date(s) of birth of child(ren) * If more than one child, separate with commas. This helps us provide a personalized search. Do you have a preference for type of child care provider? No preference Child Care Center In-Home Provider OtherOther Are there any specific needs, accommodations, or supports your child may need in a child care setting? Please share any details that would help us identify a good fit for accommodations. We will do our best to identify child care options that may meet your child’s needs. Please note that providers make their own enrollment decisions, and not all providers may have experience or training for every need. Families will contact providers directly to determine the best fit. What days of the week do you need care? (Select all that apply) * Monday Tuesday Wednesday Thursday Friday Saturday Sunday Schedule of care needed * 8:00am–5:00pm 3:00pm–11:00pm 11:00pm–7:00am OtherOther Please include approximate drop-off and pick-up times. Schedule Category * Select Schedule CategoryFull timePart timeDrop-inBefore/After schoolWeekends24 hoursOther Schedule Category Are you looking for transportation? * Transportation provided On school bus route Walking distance to school No OtherOther If transportation is needed, what is the name of the school? Your relation to children * Parent/Guardian Grandparent/Relative Foster Parent Social/Community Worker OtherOther Primary Language * EnglishSpanishSwahiliBosnianHaitian CreoleFrenchOther Primary Language What is the reason you are seeking child care? New child Changed providers Moving to the area Family dynamic change OtherOther How did you hear about us? Family/Friend Child Care Provider Hospital Library Web Search OtherOther Are you currently receiving Child Care Assistance (CCA)? * Yes No I have submitted an application If you need help paying for child care, you may be eligible through the Department of Health and Human Services Child Care Assistance Program.Phone: 866-448-4605HHS Website Would you like to receive our Parent Services newsletter? Yes No Tell me more about this. I approve to be added to all CCR&R’s newsletters Sent twice per year. Have you heard about Iowa Quality for Kids (IQ4K)? Yes No A voluntary system that recognizes providers committed to quality improvement. IQ4K – Iowa CCR&R- iowaccrr.org/child-care-providers/helpful-links/iq4k-quality-rating-improvement-system/ Is there anything else you would like us to know? We look forward to helping you connect with child care options that may meet your family’s needs. Submit If you are human, leave this field blank. Share feedback with the Parent Services Team: Parent Services Feedback
