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