First Name *

Last Name *

Phone *

Email

I confirm that I want to receive correspondence from CareArc using any contact information I provide.

Child Care Provider Name / Staff Member Name

Child Care Facility Name

Address of Facility (If Known)

City

Regulatory Concern

Illegal Child Care

Smoking

Parental Access

Background Checks

Safety

Transportation

Animals on the Premises

Supervision

Discipline (Verbal or Physical)

Diapering/Toileting

Napping/Sleeping

Overcapacity

Daily Activities/Outdoor Play

Critical Incidents

Description of the Concern (Please include complete names and ages if known)