HLHP Online Referral Form
Please complete the following form.

Parent Information
First Name
Last Name
Home Address		City	Zip
Mailing Address		City	Zip
Home Phone	( ) -
Work Phone	( ) -
Email Address
Child #1 Information
First Name
Last Name
Date of Birth	/ / (mm/dd/yyyy)
Date care needed	/ / (mm/dd/yyyy)
Child #2 Information (if applicable)
First Name
Last Name
Date of Birth	/ / (mm/dd/yyyy)
Date care needed	/ / (mm/dd/yyyy)
Child #3 Information (if applicable)
First Name
Last Name
Date of Birth	/ / (mm/dd/yyyy)
Date care needed	/ / (mm/dd/yyyy)
Child #4 Information (if applicable)
First Name
Last Name
Date of Birth	/ / (mm/dd/yyyy)
Date care needed	/ / (mm/dd/yyyy)
Select all that apply from the following options :
	Child Care Center Family Child Care Provider Group Home Provider Preschool Drop In Care
Location Desired - Include school name if applicable :
Desired Daily Time Frame :
	: ampm UNTIL : ampm
Days Needed :
	Sunday Monday Tuesday Wednesday Thursday Friday Saturday
Additional Requirements / Special Needs :