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Request Info

There are 3 ways to receive child care information from us: call your local CCR&R, search online, or submit this request form.

If you would like to receive a list of child care programs in your area, please complete the following form and your local CCR&R agency will provide the information you requested.

This is an online form that you can fill out at any time and your information will be sent directly to us. You will receive an email with information on child care programs that meet your needs. To access a printable version of this file, click here.

All fields marked with "*" must be completed before this form can be submitted.

Parent Name*:
Relationship To Child*:
Email Address*:
Address:
City: State: Zip:
Phone: Secondary Phone:
Date care is needed:
Hours care is needed:
Date of birth of child 1:
Date of birth of child 2:
Date of birth for additional children:
Days of week care is needed*
Monday-Friday
Mon
Tue
Wed
Thu
Fri
Sat
Sun
Type of care desired (check all that apply)*
Center
Family child care home
Entire year
School year
Summer only
Full time
Part time
Drop-in
Before/After school
Special needs
Other (Please specifiy)
Area / other address where care is needed (to assist us in finding the closest possible match, please enter a street address or intersection):
School district (for before & after school care):
Other needs or requests
Parent/Guardian employer (if currently unemployeed, write "none" or "looking"):

Optional Information

(Please check all that apply)
Two adult household
Single adult household
Under 20 years
Age 20-29
Age 30-39
Age 40-49
Age 50 or over
$10,000 or under
$10,000-$29,000
$30,000-$39,000
$40,000 & up

Please double-check entries before you submit this form for misspellings and empty fields.



Virginia Child Care Resource & Referral Network
308 Turner Rd, Suite A | Richmond, Virginia 23225 | (804) 285-0846