Child Care Referral Request Form
This request will generate a list of Manatee County child care providers that meet the criteria you enter below.
If you are looking for financial assistance for child care, please research our School Readiness program.
Parent's Last Name *
Parent's First Name *
Street *
City *
State
Zip *
Contact Phone # *
Email Address
Gender
Male
Female
Preferred Language
Employer
Relation to Child *
Adults in Household *
Total Number of Persons in Household/ Family Unit *
Reason For Care *
Problem Finding Care *
Referred By
Child 1
Last Name*
First Name *
Middle Initial
Date of Birth *
Click here to open the date picker
Gender *
Female
Male
Yes
No
Special Needs
If yes, please explain:
Race (optional)
Ethnicity (optional)
Hispanic
Not Hispanic
School (if enrolled)
Days Needing Care
Su
W
M
Tu
F
Sa
Th
AM
PM
Time From
AM
PM
Time To
Child 2
Last Name
First Name
Middle Initial
Date of Birth
Click here to open the date picker
Gender
Female
Male
Yes
No
Special Needs
If yes, please explain:
Race (optional)
Ethnicity (optional)
Hispanic
Not Hispanic
School (if enrolled)
Days Needing Care
Su
Tu
M
W
Th
F
Sa
AM
PM
Time From
AM
PM
Time To
Child 3
Last Name
First Name
Middle Initial
Date of Birth
Click here to open the date picker
Gender
Female
Male
Yes
No
Special Needs
If yes, please explain:
Race (optional)
Ethnicity (optional)
Hispanic
Not Hispanic
School (if enrolled)
Days Needing Care
Su
M
Tu
W
Th
F
Sa
AM
PM
Time From
AM
PM
Time To
Child 4
Last Name
First Name
Middle Initial
Date of Birth
Click here to open the date picker
Gender
Female
Male
Yes
No
Special Needs
If yes, please explain:
Race (optional)
Ethnicity (optional)
Hispanic
Not Hispanic
School (if enrolled)
Days Needing Care
Su
M
Tu
W
Th
F
Sa
AM
PM
Time From
AM
PM
Time To
Criteria
Please indicate if you have a preference for any of the following criteria.
(Hold CTRL key to select all entries that apply)
Schedule
Program
Environment
Enhanced Services
Special Needs
Transportation Needs
Curriculum
I Would Also Like Information On
Additional Comments
Are you in need of assistance paying for the cost of child care?
Yes
No
Are you currently receiving child care funding assistance?
Yes
No
Select up to five zip codes in Manatee County where you are looking for child care: *
Please indicate how you wish to receive your referrals and parent packet:

Email
Mail
Fax
Pickup at Early Learning Coalition's office
(Please contact us at 941-757-2900 to confirm completion of your referrals prior to picking up.)