The YMCA Child Care Resource and Referral serves the communities of Burnaby, New Westminster, Coquitlam, Port Coquitlam, Port Moody, Anmore and Belcarra.

For a full listing of Child Care Resource and Referrals Programs in British Columbia please visit the Government of British Columbia Child Care website.

If you would like a list of child care options in your area please complete the attached form and we will be happy to email you a list of child care providers in your area.

Personal Information

(Required fields are marked with )

	First Name
	Last Name / Family Name
	Street Address
	City
	Province
	Postal Code
	Phone
	Fax
	E-Mail

Children Who Require Care

	Child's Name	Date of Birth
Child 1:		mm 01 02 03 04 05 06 07 08 09 10 11 12 yyyy 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Child 2:		mm 01 02 03 04 05 06 07 08 09 10 11 12 yyyy 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Child 3:		mm 01 02 03 04 05 06 07 08 09 10 11 12 yyyy 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Child 4:		mm 01 02 03 04 05 06 07 08 09 10 11 12 yyyy 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Schedule Information

Select Schedule:	Days of week:
Full Time Part Time Rotating Weekends	Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Drop-off Time:	Pick-up Time:

Intended Start Date:
Do you require your child to be picked up/dropped off at school?	Yes   No
If yes, what is the name of the school your child attends?
Do you have any comments or questions?
Preferred Method of Contact:	Phone  Fax  E-Mail
How did you hear about our program?	please select one previous user from a friend from a website from Fraser Health Authority Other
If other, where did you hear about us?
Would you like to receive our parent pack?	Yes   No
Would you like to subscribe to our free newsletter?	Yes   No
Would you like information on becoming a child care provider?	Yes   No

The Child Care Resource & Referral Program is a support and referral service for families and child care providers. The names of the child care providers and/or families are provided to families by request and are in no way a recommendation of the service provided by the particular child care provider. The parent(s) has the responsibility for ensuring that the child care arrangement ultimately chosen is suitable for the family's needs.