"Tab"
through the form. ("Enter" will submit the information.)
Today's Date
Your e-mail
address
Your First Name
Your Last Name
Your Home Address
City/State/Zip
Daytime Phone Number with area code (and extension):
Where
would you like to look for child care care? (towns, zip codes,
etc.)
NOTE: We serve
ONLY the 8 counties in Southwestern Michigan (see in red above. If
you need child care in another Michigan area, call
866-4CHILDCARE (866-424-4532).
Please help us improve our
marketing services: How did you hear about Child
Care Resources, Southwest Michigan 4C ?
Please choose the best answer below:
I am a previous user of CCR's services
Phone Book
Internet Search
DHS caseworker (Michigan Department of Human Services)
CCR Flyer/Information Posted in my community
CCR Magnet/Brochure/Newsletter etc. (or another 4C)
Child Care Provider or Center Staff
Friend/Co-Worker
Another Community Agency
Community Presentation or Event
Employer Memo/Email
Michigan 4C Web site (www.Mi4C.org)
Newspaper
Radio
Chamber of Commerce
Hospital
211 Info Line
Other
If you chose "Other", please explain:
Your Employer/Company:
Your Spouse's or
Partner's Employer/Company:
Are you eligible for
assistance from the Department of Human Services to offset the
cost of child care?
Yes
No
Not
Certain
If "Not
Certain" - Would you like us to mail you an
application? Yes
Are you involved in the "WORK First" program?
Yes
No
What date do you need child
care to start?
How old will your child be
at that time?
Are you looking for:
FULL
Time care PART
Time care
What days do you need care?
What time does child need care?
(If no time
is given, the default time of 7A to 5P will be used.)
Drop Off (please indicate
Time and AM or PM)
Pick Up (please indicate Time and AM or PM)
What type of care are you
interested in?
Child
Care HOMES Child
Care CENTERS Preschools
If child needs care Before and/or After
School...
Name
of School
What date do you need child
care to start?
How old will
your child be
at that time?
Are you looking for:
FULL
Time care PART
Time care
What days do you need care?
What time does the child
need care?
Drop Off (please indicate
Time and AM or PM)
Pick Up (please indicate Time and AM or PM)
What type of care are you
interested in?
Child
Care HOMES Child
Care CENTERS Preschools
If
child needs care Before and/or After School...
Name
of School
What date do you need child
care to start?
How old will your child be
at that time?
Are you looking for:
FULL
Time care PART
Time care
What days do you need care?
What time does the child
need care?
Drop Off (please indicate
Time and AM or PM)
Pick Up (please indicate Time and AM or PM)
What type of care are you
interested in?
Child
Care HOMES Child
Care CENTERS Preschools
If
child needs care Before and/or After School...
Name
of School
Questions or Comments
regarding your search for child care:
DISCLAIMER:
Child
Care Resources does not license, endorse or recommend any caregiver,
nor can we assure you of the quality of care provided by any child
care program or caregiver. All child care programs that are referred
are licensed/registered by the Michigan
Department of Human Services, Office of Child & Adult
Licensing.
I have read the DISCLAIMER
Please read the Disclaimer and then choose
"Yes"
Yes, I have read the Disclaimer
Optional