Region Application

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How to Apply

Complete and submit the Online or PDF Child Care Application Form.
Expect an acknowledgment via email or phone call from LHCCA within 24 hours.
Select from the available child care providers nearest to your location.
If no providers are currently available in your area, your application will be added to the waiting list for up to 3 months. The waiting list is reviewed on a monthly basis.

Application Date *

Child Information *

Child DOB *

Child Address *

Child Lives With *
;Parents""Guardians""quot"

Parent/Guardian #1 *

Child Relationship *
"Father""Mother""Guardian""Other"

Other Description

Parent/Guardian #1 Address *

Cell Phone Number

Parent/Guardian #1 Email *

Employment Status *
"Employed""Student""Other"

Company/School

Address

Telephone Number

Parent/Guardian #2 *

Child Relationship *
"Father""Mother""Guardian""Other"

Other Description

Parent/Guardian #2 Address

Cell Phone Number

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Email

Employment Status *
"Employed""Student""Other"

Company/School

Address

Telephone Number

Date Home Child Care Required *

Home Child Care Days *
MondayTuesdayWednesdayThursdayFridaySaturdaySunday

Please fill in hours for each marked day

School Child Attends *

Transportation Mode *
"Car""Bus/Transit""Other"
Special Requirements

A Loving Start for a Bright Future!

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