Child Care Council of Westchester, Inc.

Child Care Request Form

Thank you for giving us the opportunity to assist in your child care search in Westchester. In order to process your request, the required fields below must be filled in.

Click on Submit at the bottom of this form when ready to send. If you have more than two children needing care, please submit an additional form.

You may use your TAB key to move forward through the fields. * = required field.
I would like a Child Care Specialist to contact me to discuss my options and other pertinent information.
	Yes No
If no, your request will be processed with the information supplied below. If the Child Care Specialist is unable to reach you, your request will be processed with the information entered on your form. Your referrals will be mailed or emailed, within 2 business days.
* First Name
* Last Name
* Address
Apt #
* City * State * Zip Code
* Phone
Alternate Phone
E-mail
* Employer
Spouse's Employer
Have you used our service before? Yes No
* You may be eligible to receive assistance with paying for child care through Child Care Subsidy, a Westchester County Scholarship, or the Sally Ziegler Scholarship. Please indicate if your household income falls in the following ranges. Family size 2 Below $36,300 Between $36,301 - $47,190 Not applicable Family size 3 Below $42,330 Between $42,331 - $55,030 Not applicable Family size 4 Below $45,000 Between $45,001 - $58,500 Not applicable Family size 5 Below $52,650 Between $52,651 - $68,446 Not applicable Family size 6 Below $60,300 Between $60,301 - $78,391 Not applicable Family size 7 Below $67,950 Between $67,951 - $88,336 Not applicable
Child 1
Child's First Name
	Boy Girl Expecting
* Date of Birth (If expecting, enter anticipated date of birth.)	Month___Day____Year
* 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.)	Month___Day____Year
* Type of Care (Check all that apply.)	Child Care Center Family Child Care Before or After School Care (School-Age Care) In-Home (Child Care in your home) Nursery School (Care for 3 hours or less) Camp/Summer Care
If care is needed for a school age child, provide the name of school your child attends.
* Desired location of care (List multiple towns or zip codes)
Child 2
Child's First Name
	Boy Girl Expecting
Date of Birth (If expecting, enter anticipated date of birth.)	Month___Day____Year
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.)	Month___Day____Year
Type of Care (check all that apply)	Child Care Center Family Child Care Before or After School Care (School-Age Care) In-Home (Child Care in your home) Nursery School (Care for 3 hours or less) Camp/Summer Care
If care is needed for a school age child, provide the name of school your child attends.
Desired location of care (List multiple towns or zip codes)
Additional Comments

For additional information, questions or concerns, call to speak to one of our child care specialists. 914–761-3456 ext. 140 Monday – Friday 9am – 5pm Disclaimer Information about the child care providers on our database is supplied by the providers themselves and has not been verified by the Child Care Council of Westchester. Therefore, we cannot guarantee a provider’s capabilities. Inclusion on the database should not be seen as an endorsement of nor recommendation by the Child Care Council of Westchester, Inc.