Use this form to make a request for Childcare services.
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Your details

Name and email address First Name*: Last Name*: Your Email Address*:

Are you male or female? Male Female

Your address Number and street / name Area Town Postcode (e.g. HD12AD) Telephone number (e.g. 01484 123123)

Care requirement details

What type of care is required? Childminder Créche Out of School Club Private Nursery Playgroup Playscheme

Where is the care required? Area of Kirklees that care is required in Choose an area Almondbury Armitage Bridge Aspley Batley Beaumont Park Berry Brow Birkby Birkenshaw Birstall Brackenhall Bradley Brockholes Carlinghow Chickenley Clayton West Cleckheaton Colne Bridge Cowcliffe Cowlersley Crosland Heath Crosland Hill Crosland Moor Dalton Deighton Denby Dale Dewsbury Dewsbury Moor Earlsheaton East Bierley Edgerton Emley Fartown Fenay Bridge Fixby Flockton Gledholt Golcar Gomersal Grange Moor Hanging Heaton Hartshead Healey Heckmondwike Hepworth Highburton Hightown Holmbridge Holme Holmfirth Honley Huddersfield Jackson Bridge Kirkburton Kirkheaton Leeds Road Lepton Lindley Linthwaite Liversedge Lockwood Longwood Lower Cumberworth Lowerhouses Marsden Marsh Meltham Milnsbridge Mirfield Moldgreen Mount Netherthong Netherton New Mill Newsome Norristhorpe Oakenshaw Oakes Outlane Paddock Primrose Hill Quarmby Ravensthorpe Rawthorpe Ray Street Roberttown Salendine Nook Savile Town Scapegoat Hill Scholes Scissett Sheepridge Shelley Shepley Skelmanthorpe Slaithwaite Springwood Staincliffe Stocksmoor Taylor Hill Thongsbridge Thornhill Thornton Lodge Upper Cumberworth Upperthong Wakefield Road Walpole Waterloo Westtown Wooldale Wyke

How many children of the age groups below is the care required for? under 5 5 - 8 9 - 14

Why is care required? Starting training or education Starting work Child requires early education Previous childcare arrangements broken down/no longer appropriate/available

Other details

Where did you hear about the childcare service?