4Cs of Alameda County is ONLY able to provide child care referrals to licensed child care programs in the following cities: Castro Valley, San Leandro, San Lorenzo, Hayward, Union City, Newark and Fremont.  In order to better assist with your request, please complete the questions listed below. Your request will be emailed to you within 48 business hours from our referral database My Child Care Plan Monday-Friday only.
If you need assistance in paying for child care or if you live in a city not listed above DO NOT complete this form and call 510-582-2182, ext. 3198 and a referral specialist can go over your options with you during our regular business hours; Monday, Tuesday & Thursday from 9am-4:30pm; Wednesdays from 9am-1:30pm and Fridays from 9am-12pm.

Basic Information

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* 1. Basic Information

Have you ever received a referral list from 4Cs before? (if yes, we will update your profile).

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* 2. Have you ever received a referral list from 4Cs before? (if yes, we will update your profile).

Are you currently receiving Cash Aid/CalWORKS for yourself or have received it within the last 24 months?

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* 3. Are you currently receiving Cash Aid/CalWORKS for yourself or have received it within the last 24 months?

Reason for Child Care - select all that apply.

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* 4. Reason for Child Care - select all that apply.

Child Care Information

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* 5. Child Care Information

Enter Date of Birth for Child #1

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* 6. Enter Date of Birth for Child #1

Date / Time
Enter Date of Birth for Child #2

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* 7. Enter Date of Birth for Child #2

Date / Time
Enter Date of Birth for Child #3

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* 8. Enter Date of Birth for Child #3

Date / Time
Enter Date of Birth for Each Additional Child Not Listed Above:

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* 9. Enter Date of Birth for Each Additional Child Not Listed Above:

When is Child Care Needed?

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* 10. When is Child Care Needed?

Date / Time
What Time is Child Care Needed? (earliest drop off and latest pick up)

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* 11. What Time is Child Care Needed? (earliest drop off and latest pick up)

What Days of the Week Are Needed for Child Care? 

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* 12. What Days of the Week Are Needed for Child Care? 

Language(s) Requested:

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* 13. Language(s) Requested:

Does Your Child Have a Special Need?

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* 14. Does Your Child Have a Special Need?

Do you need your child to be dropped off/and or picked up from school by the child care provider?

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* 15. Do you need your child to be dropped off/and or picked up from school by the child care provider?

Type of child care wanted (select all that apply):

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* 16. Type of child care wanted (select all that apply):

How did you learn about 4Cs' services?

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* 17. How did you learn about 4Cs' services?

4Cs of Alameda county provides free child care referral services to all persons requesting them, regardless of income level or other eligibility requirements. Information that we receive from parents/guardians is strictly confidential. By accepting our referral services, you understand and agree that at all times the choice of child care is and remains the parents' responsibility. 4Cs of Alameda County assumes and has no responsibility whatsoever regarding any arrangements between parent and provider, or any services that may be provided.
Please enter any additional comments below.

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* 18. 4Cs of Alameda county provides free child care referral services to all persons requesting them, regardless of income level or other eligibility requirements. Information that we receive from parents/guardians is strictly confidential. By accepting our referral services, you understand and agree that at all times the choice of child care is and remains the parents' responsibility. 4Cs of Alameda County assumes and has no responsibility whatsoever regarding any arrangements between parent and provider, or any services that may be provided.
Please enter any additional comments below.

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