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KCMS Childcare Referral: Healthcare Provider Form
Please complete this form if you are a healthcare provider looking for care for your children.
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* Indicates required question
First Name
*
Your answer
Last Name
*
Your answer
Phone Number
*
Your answer
Email Address
*
Your answer
Zip Code
*
Your answer
How many children do you need care for?
*
Choose
1
2
3
4
5+
What are the age ranges of your children?
*
Infant (12 months and under)
Toddler/ preschool
School age (5 and up)
Required
Will you need care for a child who has special needs?
Yes
No
Other:
Clear selection
Will you need care in another language other than English? If so, please list the language(s) below.
Your answer
Please indicate your need for childcare. Check all that apply.
*
Morning: 6AM - 12PM
Afternoon: 12PM - 6PM
Evening: 6PM - 12AM
Overnight: 12AM - 6AM
Not needed
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Morning: 6AM - 12PM
Afternoon: 12PM - 6PM
Evening: 6PM - 12AM
Overnight: 12AM - 6AM
Not needed
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
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