CCC Child Care: Free Child Care Request Form
WHO: We are local organizers who are looking to help health care providers in Los Angeles who need help managing their household while serving at the frontlines during COVID-19. Most of our volunteers are high school and college students with babysitting experience.

WHAT: This form is intended for ALL healthcare workers (MD, DO, NP, RN, Pharm. D, Med Tech, Custodial staff, etc.) in Los Angeles looking for help with childcare/babysitting, virtual tutoring, grocery runs, and/or pharmacy runs during COVID-19.

WHY: We want to support you as best as we can during this important time of community effort! It takes a village! Please direct all questions to la.covidchildcare@gmail.com or contact us at www.covid-childcare.org 

HOW: After completing this form, we'll do our best to pair you with volunteers that meet your requirements. Then, we'll reach out to you with several volunteers' contact information, and you'll be able to contact them at your discretion.

Please note that this service is flexible and might change daily. We will do our best to support you! In return, we ask for your timely response to volunteers and to be aware of our own limitations. Unfortunately, not all requests will be fulfilled immediately.

IMPORTANT: CCC Los Angeles is not a certified child care provider, and our volunteers do not undergo any form of background checks. After we send you (the medical worker requesting help) the contact information of one or multiple volunteers, you assume all vetting responsibilities. Please carefully read and sign the agreement below titled “Agreement for Parents and Legal Guardians.” Thank you!
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Full Name *
Cell Phone Number *
Email Address *
Employer (e.g. Ronald Reagan UCLA Medical Center) *
Job Title *
When do you need a babysitter? If you don't have exact days and times, please estimate--we know there is a lot up in the air.                                                                                                                      Please follow this format:  Mondays 9am-5pm, Wednesdays 3pm -7pm, etc.                                                (If you don't need babysitting, type n/a) *
Age of child or children (e.g. 5 and 8) *
Can the babysitter look after your children at your residence? *
If "no" to previous question, please elaborate.
City of Residence (e.g. Westwood) *
Please list the name, relation, and phone number of at least one emergency contact for your child/children *
If you need services besides or in addition to babysitting, please specify here. (i.e. grocery shopping, errands, etc.)
Does your child need tutoring? If so, please out this form using this link: https://docs.google.com/forms/d/1F9uE3G4LRIaZceiAFTvUm1MuCaOBQ8H6LQtojgZSJ_E/edit?usp=drive_web
Do you need our services immediately? *
Please add any additional comments/thoughts or anything else we should know about your family or your home so we can make the best volunteer connection for you. (e.g. need Spanish speaker, etc.)
Do you work with COVID-19 infected patients? Your answer will not impact your application for our free services.
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Have you received the COVID-19 vaccine? If yes, how many doses have you received?
How did you hear about us? *
Agreement for Parent and Legal Guardians 1 of 2
Agreement for Parent and Legal Guardians 2 of 2
Parent / Legal Guardian Signature (type full name) *
Today's Date (MM-DD-YYYY) *
Parent / Legal Guardian #2: Signature                                                                                                                           (if there are multiple parents/legal guardians)
Date (MM-DD-YYYY)
Submit
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