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Find Child Care > Child Care Request Form

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

You may use your TAB key to move forward through the fields.
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.

Would you like…
A Child Care Specialist to contact you to discuss your child care options and other pertinent information?

  Yes        No

(However, if the Child Care Specialist is unable to reach you, your request will be processed with the information entered on your form.)

OR

Would you like…
Your child care referrals to be emailed and/or mailed to you, based on the information you have supplied below?

  Yes        No

If you supplied an email address, your referrals will be emailed to you within 2 business days. You may need to check your spam or junk mail because often our emails are not filter properly. Contact us if you do not receive an email from us within 3 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
Are you requesting referral because your e-child care search was not successful?   Yes        No
Do you currently have an income? Yes        No
Are you employed? Yes        No
What is your family size?
*
Would you like someone to contact you related to possible assistance to pay for child care? Yes        No

If yes, someone will contact you within 2 business days by phone or by email.

Family size 2
Below $29,140 Between $29,141.00 - $40,067.50
 Between $40,067.51 - $48,081.00  Above $48,082.00

Family size 3
Below $36,620.00 Between $36,621.00 to $46,690.50
 Between $46,690.51 - $56,029.00  Above $56,030.00

Family size 4
Below $44,100.00 Between $44,101.00 to $49,612.50 
 Between $49,612.51 - $59,535.00  Above $59,536.00

Family size 5
Below $51,580.00 Between $51,581.00 to $58,027.50 
 Between $58,027.51 - $69,633.00  Above $69,634.00

Family size 6
Below $59,060.00 Between $59,061.00 to $66,442.50 
Between $66,442.51 - $79,731.00  Above $79,732.00

Family size 7
Below $66,540.00 Between $66,541.00 to $74,857.50 
Between $74,857.51 - $89,829.00  Above $89,830.00

Family size 8
Below $74,020.00 Between $74,021.00 to $83,272.50 
 Above $83,272.51
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

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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.