Colorado Shines Child Care Referral at Mile High United Way Licensed Child Care Request

Information About Parent/Legal Guardian

Parent/Guardian Name*

Have you contacted us in the past?*

Yes
No
Unsure

Email address (to send the list of licensed child care providers)*

County of residence*

Home Address*

Street Address Address Line 2 City State ZIP Code

Search for child care around this address?*

Yes
No

If searching for child care in a different area, please include full address below

Street Address Address Line 2 City State ZIP Code

Information About Children

If child is not yet born "unknown" may be entered under name and the child's due date may be entered in place of birthdate.

Child's First Name*

Child's Birthdate*

Date child care is needed*

Child's First Name

Child's Birthdate

Date child care is needed

Child's First Name

Child's Birthdate

Date child care is needed

Child's First Name

Child's Birthdate

Date child care is needed

For any additional children, please include their information in the text box below

Search Information

Please let us know about your child care needs

Financial Assistance*

CCAP
TANF
None

Please select the days you need child care*

Select All
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Please specify child care start time*

: HH

MM

Please specify child care end time*

: HH

MM

Type of licensed care desired*

Child Care Center
Family Child Care Home
Preschool
School Age Care

Special Needs

Social Emotional Behaviors
Respiratory Illness
Diabetes
Seizure Disorders
Physical Delays/Limitations
Food/Dietary
Medical/Special Procedures
Cognitive Delays
Speech/Communication

Extra Care Services

24 Hour
After School
Before School
Drop In
Temp/Emergency
Transportation (to and from school)

If transportation is needed, please include the name of school child attends

Would you like to share additional information about your child care needs?

Optional Demographic Information

The questions below are not required, but if you decide to answer them, it will help us serve our community better.

Relationship to Child

Parent/Guardian Age

Gender

Annual Household Income

Total Family Size

Please enter a number from 2 to 20.

Single Parent Household

Referred by