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Parent Child Care Needs Registration Form

The Alexandria Emergency Child Care Collaborative, which was formed to support essential workers in need of child care who have exhausted all other non-group care options, now supports all families in need of child care and works to match them with open providers.

If you are in need of child care, please complete this form for submission to the Department of Community and Human Services (DCHS), Office of Early Childhood Emergency Child Care Collaborative.

1. Parent/Guardian Information

Email Address *This question is required. This question requires a valid email address.

Parent/Guardian First and Last Name *This question is required.

Primary Phone Number *This question is required.

Secondary Phone Number

Home Address (Provide the home street number, street name, and unit/apt number, if applicable.) *This question is required.

City *This question is required.

ZIP Code *This question is required.

2. Please rank your preference for types of child care. First (1) is your most desired and last (3) is your least preferred. If no preference, you may leave this blank. Note: for the following table each column is restricted to a single answer across all rows.

	1	2	3
Family Day Home Care	Rank Family Day Home Care as 1 out of 3	Rank Family Day Home Care as 2 out of 3	Rank Family Day Home Care as 3 out of 3
Micro Pod/Quaranteam	Rank Micro Pod/Quaranteam as 1 out of 3	Rank Micro Pod/Quaranteam as 2 out of 3	Rank Micro Pod/Quaranteam as 3 out of 3
Child Care Center	Rank Child Care Center as 1 out of 3	Rank Child Care Center as 2 out of 3	Rank Child Care Center as 3 out of 3

Please provide the employment information of the named parent/guardian.

3. Field of Work *This question is required.

Please provide additional employment information regarding your employment in critical services.

4. Critical Services if Applicable (Select an option below that best describes your employment in critical services or leave blank if not critical services)

5. Employer Information

Employer Name *This question is required.

Employer City *This question is required.

Employer ZIP Code *This question is required.

Employer Website (if known)

Position/Job Title (Provide the position/job title of the parent/guardian whose job involves providing an essential service.) *This question is required.

If your job is an Essential Function, please describe.

Supervisor Name

Supervisor Email This question requires a valid email address.

6. Household Information

What is the Total Number of People in Your Household (including yourself)? *This question is required.

How Many Children in Your Household Are in Need of Care? *This question is required.

What is Your Annual Gross Household Income? (Annual gross income is your household's total income before deductions, taxes, and expenses. This information will help DCHS Early Childhood ECCC identify other support programs for which you may be eligible.) *This question is required.

Is Any Other Member of Your Household Considered Essential Personnel? *This question is required.

What Days of the Week is Child Care Needed? *This question is required.

What Hours is Child Care is Needed (ex. 8 a.m. - 12 p.m.)? *This question is required.

Please provide the requested information for your child who is in need of care. There will be a separate section for each child if you have more than one who is in need of care.

7. Child Information

8. By electronic signature below, I hereby certify that the information provided is true and accurate to the best of my knowledge. I consent for my information to be shared by the Alexandria Department of Community and Human Services, and their partners to facilitate enrollment in the program. I permit for these entities to contact me to assist with eligibility and enrollment. *This question is required.