Change of Provider FormPlease enable JavaScript in your browser to complete this form. - Step 1 of 2Reason *Adding a ChildAdding a ProviderChanging a ProviderParent 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 InformationParent Name *FirstLastParent Email *Provider InformationProvider Name *FirstLastFirst Day of Care *Last Day of CareProvider Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeProvider Phone *Provider Email *Does the provider offers the child a robust school readiness experience? *YesNoIs your child care provider licensed (center or family child care home)? *YesNoDoes this child care provider provide child care for other families? *YesNoHas the provider had a Trustline background check??YesNoNextChild Information*** Please list all the children using child care from the provider above ***How many Children need care? *One (1)Two (2)Three (3)1st Child Information1st Child Name *FirstLast1st Child DOB *1st Child Care Start Date **** Care can only start Two Weeks from Today ***1st Child Care is being provided in *Child's HomeProvider's HomeLicensed Family Child Care Home or CenterIs the 1st Child potty trained *YesNo***Following is for school age kids only***1st Child School Name1st Child School District1st Child Monday In1st Child Monday out1st Child Tuesday In1st Child Tuesday Out1st Child Wednesday In1st Child Wednesday Out1st Child Thursday In1st Child Thursday Out1st Child Friday In1st Child Friday Out2nd Child Information2nd Child NameFirstLast2nd Child DOB2nd Child Care Start Date*** Care can only start Two Weeks from Today ***2nd Child Care is being provided inChild's HomeProvider's HomeIs the 2nd Child potty trainedYesNo***Following is for school age kids only***2nd Child School Name2nd Child School District2nd Child Monday In2nd Child Monday out2nd Child Tuesday In2nd Child Tuesday Out2nd Child Wednesday In2nd Child Wednesday Out2nd Child Thursday In2nd Child Thursday Out2nd Child Friday In2nd Child Friday Out3rd Child Information3rd Child NameFirstLast3rd Child DOB3rd Child Care Start Date*** Care can only start Two Weeks from Today ***3rd Child Care is being provided inChild's HomeProvider's HomeIs the 3rd Child potty trainedYesNo***Following is for school age kids only***3rd Child School Name3rd Child School District3rd Child Monday In3rd Child Monday out3rd Child Tuesday In3rd Child Tuesday Out3rd Child Wednesday In3rd Child Wednesday Out3rd Child Thursday In3rd Child Thursday Out3rd Child Friday In3rd Child Friday OutPreviousSubmit This form is currently under construction. Please fill out our New Client Enrollment Form with your new provider’s information at this time. Photo by Element5 Digital on Unsplash
