Child Care Referral Form

*If you are seeking child care in an area not served by the Victoria CCRR (ex. Colwood, Langford, or Sooke as well as the Saanich Peninsula and Gulf Islands), please visit the CCRR Directory Page to look for your local CCRR program.

Your Information

*Please be sure to fill out all mandatory fields.
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
Preferred Contact Method*
- Email
- Phone
Your Child(ren)'s Information
Number of children who require care*
- 1
- 2
- 3
- 4
Child 1 Name*
First
Child's Birthday*
Month
Day
Year
Child 1 Name*
First
Child's Birthday*
Month
Day
Year
Child 2 Name*
First
Child's Birthday*
Month
Day
Year
Child 1 Name*
First
Child's Birthday*
Month
Day
Year
Child 2 Name*
First
Child's Birthday*
Month
Day
Year
Child 3 Name*
First
Child's Birthday*
Month
Day
Year
Child 1 Name*
First
Child's Birthday*
Month
Day
Year
Child 2 Name*
First
Child's Birthday*
Month
Day
Year
Child 3 Name*
First
Child's Birthday*
Month
Day
Year
Child 4 Name*
First
Child's Birthday*
Month
Day
Year
Child Care Preferences
Not sure what type of care you are looking for? View types of child care in BC.
Type of Care
Hours of Care*
- Full-time
- Part-time
Start Date*
Month
Day
Year
Start Time*

: Hours

Minutes

AM/PM
Pick-Up Time*

: Hours

Minutes

AM/PM
Child Care Close To*
- Home
- School
- Work
- Other
School Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Work Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Other Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Do your children need to be picked-up from or dropped off at school?*
- Yes
- No
If yes, at which school?*
Additional Comments
Notes
Date
MM slash DD slash YYYY

* Please note: In the best interest of families, no recommendations or endorsements of individual child care facilities or programs are made. The responsibility for selecting child care rests with families who, when well-informed, are best able to select and evaluate services that meet their needs. View full disclaimer

Child Care Referral Form

Your Information

Your Child(ren)'s Information

Child Care Preferences

Additional Comments