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Are you an essential worker and need Child Care? (click here). COVID-19 Essential Worker Forms and Resources

Choices For Children Mission

Choices for Children’s mission is to enrich children’s lives through innovative support, education and enhanced family and provider services. Our programs put families at the center of a community of support services.

Child Care Form

COVID-19 Essential Workers Child Care Request Form
1. Check the one that applies:*
- Health Care Provider (i.e. Nurse, Physician)
- Hospital and Health Care Support Staff (i.e Clerk, Custodial Staff, Environmental Services, Admin)
- 1st Responder (i.e. Firefight, police, paramedic, EMT)
- County Essential Staff (i.e. ACPHD, Child Welfare Staff)
2. Current Role / Title:*

COVID-19 Essential Workers Child Care Request Form
[CONTACT INFORMATION]
3. First Name*
4. Last Name*
5. WORK Email Address*
6. Phone Number*
7. Preferred Language*
7a. Total Family Income*

COVID-19 Essential Workers Child Care Request Form
[HOME ADDRESS]
8a. Street Address (HOME)*
Street Address
8b. City (HOME)*
City
8c. Zip Code (HOME)*
ZIP / Postal Code

COVID-19 Essential Workers Child Care Request Form
[WORK ADDRESS]
9a. Employer Name*
9b. Street Address (WORK)*
Street Address
9c. City (WORK)*
City
9d. Zip Code (WORK)*
ZIP / Postal Code

COVID-19 Essential Workers Child Care Request Form
[CHILD CARE NEEDS]
10. Location of Care Needed (List Preferred City)*
11a. Child (1) Name or Initials*
11a. Child (1) Date of Birth*
11a. Child (1) current childcare provider’s name*
11b. Child (2) Name or Initials
11b. Child (2) Date of Birth
11b. Child (2) current childcare provider’s name
11c. Child (3) Name or Initials
11c. Child (3) Date of Birth
11c. Child (3) current childcare provider’s name
12a. Dates Child Care is needed (START DATE)*
12b. Dates Child Care is needed (END DATE)*
13. Check Applicable SCHEDULE of Care Needed:*
- i. Drop-in, on-call
- ii. Evening (after 7p)
- iii. Overnight
- iv. Before School
- v. After School
- vi. Regular Day (8a – 5p)
- Other
14. Check All Applicable DAYS of Care Needed*
- a. Sunday
- b. Monday
- c. Tuesday
- d. Wednesday
- e. Thursday
- f. Friday
- g. Saturday
15. Please share any additional comments about the schedule of care needed:*
16. Do your children have any special needs as covered under the Americans with Disabilities Act (i.e. asthma, difficulty hearing, blind, etc.)? – If YES, please provide as much detail as possible.*

COVID-19 Essential Workers Child Care Request Form
[PREFERENCES] - OPTIONAL
17. Check what most closely aligns to your current situation. Child Care Location:*
- Care should be near WORK
- Care should be near HOME
18. If you have more than one child, check what most closely aligns to your current situation:*
- Prefer children be at same location
- Ok if children are at separate locations
19. Other Information – Please share any additional information that may be pertinent to care*
Thank you!
One of our Child Care Subsidy Counselors will contact soon!

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20 Great Oaks Blvd. Suite 200
San Jose, CA 95119
Mon – Fri, 8:30AM – 5:00PM
408-297-3295

1165 Scenic Dr, Ste C-4
Modesto, CA 95350
Mon – Fri, 8:30AM – 5:00PM
209-860-5030

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