Referral Request

If you would like assistance locating child care, please fill out this form. For Option information please see How to Get Referrals from Child Care Connections.

Choose your option.
Free list
CCC Annual Membership Plus

Name:

Address:

City/State/Zip

Home Phone:

Place of Employment:

Work Phone:

Fax:

E-Mail:

Clients Age:
Under 20 Years of Age 20-29 Years of Age 30-39 Years of Age 40-49 Years of Age 50 Years or Over

Family Size:

Adults:
Single Adult in Household
Two or More Adults in Household

Relation to Children:
Father Mother Grandparent Guardian Relative Friend Other

Choose type(s) of child care:
Center
Family Child Care Home
Nursery School
Centers & Family Child Care Homes

Legal, Unlicensed Care (click here for information about this type of care)

Schedule: enter the days of the week and times you need care. Be specific, AM/PM.

List the town(s) care is needed: near home, near work, near child's school-name of school, other):

Additional Comments (i.e. allergies, smoke-free, pet-free)

Number of Children Needing Care:
1
2
3
4
5

Child #1 Birthday (mm/dd/yy) Age:

Child #2 Birthday (mm/dd/yy) Age:

Child #3 Birthday (mm/dd/yy) Age:

Child #4 Birthday (mm/dd/yy) Age:

Child #5 Birthday (mm/dd/yy) Age:

Date Care Needs to Begin:

Would you like to receive information about financial help for child Care?
Yes
No

Thank you for taking the time to complete this form. Please copy this information into an email to ccc@smaaa.org to send us your information. You can also fax this form to 207-396-6581.  We will be contacting you soon.

Contact info:
Child Care Connections

136 U.S. Route One

Scarborough, ME 04074

207-396-6566, ext. 574