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PCOE Child Care Services
To request child-care referrals by e-mail, please complete the form below so we may contact you with appropriate referrals for your family. If you prefer to contact PCOE Child Care Services by phone, please call 530-745-1380.

Name		Street Address
City		State	Zip
Home Phone		Alternate Phone
E-mail Address		Fax
How would you like to receive information?

Nearest Elementary School (This information helps us locate child care near your home.)

If you are looking for care in another city, please tell us which city:

* Please include child's birthdate and hours childcare is needed.
	First Name	Birthdate *	Days Needed	Hours Needed *
Child 1
Child 2
Child 3
Child 4
Child 5

Date Care Needed

Type of Care Preferred:
Child Care Home		Child Care Center
In-Home (Nanny)

Require Special Services for:
Transportation to/from elementary school
Special Needs		Toilet Training

If your child has special needs, please describe the special needs:

Employer


Special Instructions for Resource and Referral Counselor:

Submit this form by clicking on the button so we may contact you with information that will help you find the best care for your family: