Early Care and Education Request for Information

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The ESD 112 Early Care and Education Department provides a variety of services for children ages 4 weeks - 12 years. Some services are *FREE* to families who qualify. We provide services in Clark, Cowlitz, Klickitat, and Pacific counties.

If you would like one of our program staff to reach out to you regarding our services, please complete the following survey.

ESD 112 respects your right to privacy. Information obtained is for the purpose of identifying which programs you may be eligible for and will not be shared with third parties.

Parent/Caregiver First & Last Name: *

Parent/Caregiver Phone Number: *

Parent/Caregiver Email Address:

Child's First & Last Name: *

Child's Date of Birth: *

YYYY

Are you looking for services for more than one child? *

Yes

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