Change of Provider Form

Step 1 of 2

Reason *

Adding a Child
Adding a Provider
Changing a Provider

Parent and Provider Information

*** Child Care reimbursement may only start two Weeks from today. Your non-licensed child care provider will not be paid until a Fingerprint Background Clearance is received and the provider enrollment is complete with 4Cs of Alameda County ***

Parent Information

Parent Name *

First

Last

Parent Email *

Provider Information

Provider Name *

First

Last

First Day of Care *

Last Day of Care

Provider Address *

Address Line 1

Address Line 2

City

State

Zip Code

Provider Phone *

Provider Email *

Does the provider offers the child a robust school readiness experience? *

Is your child care provider licensed (center or family child care home)? *

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Parent and Provider Information

Parent Information

Provider Information

Child Information

1st Child Information

Following is for school age kids only

2nd Child Information

Following is for school age kids only

3rd Child Information

Following is for school age kids only

Parent and Provider Information

Parent Information

Provider Information

Child Information

1st Child Information

***Following is for school age kids only***

2nd Child Information

***Following is for school age kids only***

3rd Child Information

***Following is for school age kids only***

Following is for school age kids only

Following is for school age kids only

Following is for school age kids only