Child Care Request Form

Please use the search request form below if you would like a referral for Family Child Care Providers on the Intel Provider Network.

Employee Name

First Name

Last Name

Phone Number

(###)

###

####

Best Time to Contact

Hour

Minute

Second

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Intel Location

Comments

Badge Color

WWID#

Shift

1st Child's Name

First Name

Last Name

1st Child's Birth Date

(if you are expecting a baby, please enter your expected delivery date)

YYYY

2nd Child's Name

First Name

Last Name

2nd Child's Birth Date

YYYY

3rd Child's Name

First Name

Last Name

3rd Child's Birth Date

YYYY

4th Child's Name

First Name

Last Name

4th Child's Birth Date

YYYY

Date you need care to begin

YYYY

Days care is needed

Please enter the day(s) for which you need care (Mon, Tue, Wed, Thu, Fri, Sat, Sun)

Hours Care is needed

Pick up, and Drop off time (please specify AM or PM)

Search Area

(please include specific cross streets or a mileage radius)