Referral Request Form - Parent Aware

Child Care Referral Request

Do you need additional help from one of our Child Care Referral Specialists? Please complete this form, and we will respond to your inquiry as soon as possible (Monday through Thursday, 8 a.m. to 4 p.m., Friday, 8 a.m. to 3 p.m.).

URL

This field is for validation purposes and should be left unchanged.

For free help in other languages, please call 888.291.9811. Para ayuda gratuita en español porfavor llame al 888.291.9811. Si aad u hesho turjumaan Soomaali ah, fadlan wac 888-291-9811. Yog xav tau kev pab siv lwm yam lus, hu rau 888.291.9811.

First Name(Required)

Last Name(Required)

Email Address(Required)

Enter Email Confirm Email

Phone Number

Mobile Number for Text

Full Address Closest to Where I Need Care(Required)

Street Address Address Line 2 City State ZIP Code

Birthdates (Month and Year) of Children Needing Care(Required)

This information helps us find the correct type of care. Enter as MM/YYYY (e.g., 04/2022) and add a row for each child.

Days/Hours I Need Care(Required)

Weekdays, Monday-Friday

Other

Please Specify Other Days(Required)

Start Time(Required)

End Time(Required)

Does your child have special needs? If so, please select from the list below.

Developmental Delay (such as autism, speech, cognitive, social and/or motor delays)

Emotional/Behavioral (such as ADHD/ADD)

Hearing Impaired

Special Health Needs (such as asthma, special diet or Hepatitis B)

Physically Challenged

Visually Impaired

Additional Information You Would Like Us to Know

Referral Services Disclaimer: This information is intended for referral purposes only. Parent Aware/Child Care Aware of Minnesota does not license, endorse, or recommend any child care or early education program. Families are responsible for choosing the appropriate provider for their children. Parents and guardians are strongly encouraged to tour the child care facilities, review license history, and check references before leaving a child in care.

Tennessen Warning: In accordance with the Minnesota Government Data Practices Act (Minnesota Statutes chapter 13), Child Care Aware of Minnesota (CCAoMN), a grantee of the State of Minnesota, is providing you with this privacy notice. To collect and use private/confidential data and personal information, we must tell you why we need the data, how we intend to use it, and the outcomes you may experience if you provide the information or not.

You may refuse to provide any or all this information. You are not legally required to provide information about yourself or your child when seeking referrals through our toll-free hotline or chats through ParentAware.org. However, if you do not provide sufficient information, it may limit our ability to provide services to you, and any referrals provided may not meet your needs. Your information may be shared with State of Minnesota agencies, with contractors who need this information to do their jobs, with researchers conducting evaluations of this program, in response to court orders, as required by the State or Legislative Auditor, and as otherwise authorized or allowed by law.