Protective Services Child Care Authorization Request   
 

Parent Information
       
* Resource Parent Name:  Resource Parent DVN:

       
* Resource Parent Phone Number:
 Resource Parent Email Address:
       
County and Worker Information
Child Information
Last NameFirst NameDOBDCNDoes child function at age lower than his/her current age?Age GroupAttends School 


Yes No Delete



Reason For Child Care Need:
* Reason For Child Care Need:  
       
* Child Care Provider Name: * Child Care Provider Phone Number:
       
  Child Care Provider DVN :
   
     
       
* Care Needs to Begin Date
       
Units Of Care
   
  * Day Of The Week Care is Needed
 
   
  * Start Time
* End Time
 
 
   

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