EMAIL FORM
Caretaker Name:
Spouse's Name:
Child's Name:
Birth Date:
Child's Name:
Birth Date:
Child's Name:

Birth Date:

Email:

Address:
Address 2:

City:
Zip Code:
Employer:
Home Phone:
Office Phone:
Provider:
How did you first hear about CCIS?

Internet

Friend/Relative

Provider

County Assistance Office

Other

Print this form and Fax to

(814)-472-4640, or mail to:

C.C.I.S.
Attn: O. Poruban
300 Prave Street, Suite 101
Ebensburg, PA 15931

Child Care Providers Fees Starting A Child Care Center Resource & Referral Services

Child Care Information Services of Cambria County State Regulations for Providers Checklist for Choosing a Child Care Provider

Home Enrollment From

Admissions, the provision of services, and referrals of clients shall be made without regard to race, color, religious creed, disability, ancestry, national origin, age, or sex.

Neither DPW nor the CCIS guarantees the quality of service delivered by the provider and is not responsible for any act or failure to act by the provider. All information about the providers have been obtained from the providers.