To Apply for a Provider Referral please fill in the spaces provided on your screen, then print. Provide the additional items listed below and mail to the address. a) copy of current family child care license RCFCCA, Referral, PO Box 7434, Riverside, CA 92513
Last Name First Name MI Zip Code
Business Name Business Phone number Fax Number
Mat Your Phone Number be Given Out For Referrals? Yes No
City Area or General Location of your home,
Major Cross Streets
Closest Elementary School License Number
Family to Family Participant? Yes No NAFCC Accredited? Yes No CDA? Yes No
Early Childhood Education? Yes No If yes, specify #of ECE Units
Ages of children Accepted. (Example - Infants only, Toddlers only, Preschool only, School age only, Birth through twelve years and, etc.)
Do you have any training, education or experience working with children with special needs? Yes No If yes please explain
Days of the week you are open for business?
Business Hours AM to PM
Do you provide full time child care?
Yes
No
Do you provide part time child care?
Yes
No
Do you provide drop in child care?
Yes
No
Do you provide rotating schedule child care?
Yes
No
Do you provide holiday child care?
Yes
NO
Do you provide transportation to and from school?
Yes
No
Do you provide weekend child care? Yes No If Yes, regularly , occasional , emergency only .
Do you provide evening child care? Yes No If Yes, regularly , occasional , emergency only .
Do you provide meals and snacks? Yes No If Yes, Breakfast , Lunch , Dinner , Snacks .
Do you participate in a Child Care food program? Yes No
If Yes, Name of the food program sponsor?
Home language spoken? Do you know Sign Language? Yes No Are you bilingual? Yes No
