HACCPN does not warrant information concerning any providers nor do we license, endorse or recommend any particular provider. It is the sole responsibility of parents to verify that the provider meets all registration requirements for their area.

*(asterisks mark required fields)

*Parent's Name(s):
*Child's Name:
*Gender of Child:	M F
*Age:	<1 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15
*Date of Birth:
*Full Time / Part Time / Variable Hours?
*When do you desire child care to begin?
What type of program do you desire? (Preschool, Play Group, Part-Time, etc.):
Town/Area Preferred?
What are your current child care arrangements?
Other information you would like to share? (examples include: Single Parent, On Call Needs, Government Subsidy Assistance, After School Care, Transportation Issues, etc.)
*Please provide the following information so that we can contact you:
Home Phone and best time to call:
Work Phone (if convenient) and preferred time:
E-mail Address:
Other: