KidCare Referral Services
 (210) 65-SMART (657-6278)


For help finding child care, please fill out this form and let our Kid Care Referral Specialists find choices that meet your needs.

Name:

Phone:

Address:

Zip Code:


Work/School Place:

 Phone:

Work/School Address:

Zip Code:

 

Child One Child Two Child Three
Name:
Date of Birth:
Any Special Needs:
Hours of Care Needed:
Days Care Needed:
S M T W Th F Sat

S M T W Th F Sat
S M T W Th F Sat
Child's School:

 

Please Mark All that Apply:
Where do you want care: Near Home Near Work/School Near Child's School
Type of Care: Licensed Center Licensed Group Home Registered Home
Type of Program: Academic Montessori Infant/Toddler
Religious Child Development Kindergarten
Mother's Day Out After School Care Pre-Kinder

 

How did you learn about KidCare Referral Services:
Family/Friend

Employer

 United Way Television Our Kids Magazine
City Web Page Newspaper Military Flyers Showcase
Child Care Management Services Texas Department of Human Services
Texas Workforce Commission Local Workforce Board Other

 

How do you want to receive your referrals?

Fax

Fax Number:

Phone

Phone Number:

Mail

This will use the address at top of form.

E-mail

 E-mail Address: