CCRR Online Info Request Form

Assisting You in Your Search for Quality Child Care

How the child care provider listing process works: Our computer will generate listings based on a match between your needs and child care providers in our database. After you submit an online request, we will generate a listing with a packet of information to help you with your choice. We can e-mail or mail you this information, or you can pick it up in person at your local R&R office. Please check below how you would like to receive your child care provider listings and informational packet (Email, Postal Mail, Fax, Pick-Up).
If you would like to speak with someone about CCR&R Services or about Provider Listings, please do not hesitate to contact us as one of our local offices:

Administrative Office: 1-800-238-3463 or 1-904-726-1500 ext. 7055

Fax: (904) 726-1516

Baker County: 904-259-4225
Clay County: 904-213-3939
Nassau County: 904-432-0009 ext. 2626
Bradford County: 904-964-1543
Putnam County: 386-385-3450
St. Johns County: 904-770-2565

All information you submit is strictly confidential. Only the School Readiness Agency and/or the Florida Department of Law Enforcement may request information relating to your eligibility and/or make an inquiry about information given. Privacy Policy

Information Delivery

Preferred Delivery Method

Email US Mail Fax In person pick-up

Preferred Method of Contact

If we have questions about your submission, how would you prefer us to contact you? Please Note: if we are unable to contact you with the preferred method, we will attempt to contact you with the alternate mode.

Email Phone

County Area (Listings)

St Johns Putnam Clay Nassau Baker Bradford

Location

In order to provide you with child care listings in your preferred area, please provide us with one or more of the following information: zip code, city name, section of city.

Preferred Language

English Spanish Other (Please Specify)

Other Language (Specify)

Applicant Information

Last Name

First Name

Parent/Guardian DOB

Marital Status

Select One

Your Email

Home Address

 

Home Zip Code

Phone Number

Relationship to Child

Mother Father Guardian Relative Caregiver Other

If Other, please list

Reason for Care

Caregiver No Longer Available Employment School/Training Moved to New Area/Relocation Customer asked to leave program Hurricane/Disaster Cost too high Parent/Child Needs Unhappy with the quality Other Refuse to Answer

Child Care Issues

Affordability Location/Transportation Schedule Care Ending No Openings Special Needs Curriculum/Program Quality Type of Care Other N/A Refuse to Answer

Referred by:

Newspaper/Magazine Billboards Brochure/Poster DCF Employer/Business Friend/Relative Division of Early Learning Licensing Radio Ad Early Learning Coalition School or Provider Word of Mouth Television Social Media Website Other

Child(ren) Information

Child First Name

Child Last Name

Child Date of Birth

Sex/Gender

Male Female Do not wish to disclose

Special Needs

List Special Needs Services

Days of the Week

Sunday Monday Tuesday Wednesday Thursday Friday Saturday

Time care is needed (start time)

Time care is needed (end time)

Provider Preferences

Type of Care

Center Family Child Care Home Large Family Child Care Home Gold Seal Provider Licensed Exempt

Schedule

24 Hour Care Drop-In Care Full-Time Part-Time After School Before School Respite Care Overnight Weekend Care Summer Only School Year Emergency/Temp Care

Programs

Play Group Quality Rating System Sick Child Care VPK Military Private School School Age Programs Teen Parent Public School School Readiness Provider Summer Camp n/a

Additional Child(ren)?

Additional Child(ren)

Child 2 First Name

Child Last Name 2

Child 2 Date of Birth

Parent Note

Optional Section

Curriculum/Learning Program

No Preference Bee All You Can Bee Beyond Centers and Circle Time Beyond Cribs and Rattles The Creative Curriculum Develop Inspire and Grow Every Child Ready Fireflies Frog Street Funnydaffer Funshine Online Galileo HighScope Mother Goose Nemours Quaver Starfall Wee Learn World of Wonders Montessori Reggio Emilia HighReach Learn as We Grow Wonder of Learning Waldorf Other (please list)

List Curriculum

Environment

Accomodates Allergies Creole Chinese Cat Dog English French German Greek Hebrew Italian No TV Pool On Site Russian Spanish Sign Language Smoke Free Video Monitoring Wheelchair Accessible Other (list)

List Other Environment

Transportation

School Bus/Van Transport to Child's Home Transport from Child's Home Near Public Transportation Walking Distance from School

List Any Enhanced Services

Other Information Requested

Emergency Family Services/211 Parent Education/Training Information Hurricane/Disaster Other (please list)

List Other Requested Information

SUBMIT ONLINE CCR&R REQUEST