Weekday Early Education Program
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1. Default Section

1. This information is not required, but would be useful for us to communicate with you if the Weekday program is started.

This information is not required, but would be useful for us to communicate with you if the Weekday program is started. Name:
Address:
City/Town:
State:
ZIP/Postal Code:
Email Address:
Phone Number:

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2. Number of children in household:

	1	2	3	4	5	6
Birth-3 years	*Number of children in household: Birth-3 years 1	Birth-3 years 2	Birth-3 years 3	Birth-3 years 4	Birth-3 years 5	Birth-3 years 6
4-6 years	4-6 years 1	4-6 years 2	4-6 years 3	4-6 years 4	4-6 years 5	4-6 years 6

*
3. Are you working now?

Are you working now? Full-Time

Part-Time

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4. If weekday education services are offered, check the ones you would use.

If weekday education services are offered, check the ones you would use. Full Weekday Early Education (School day hours plus earlier/later drop off and pick-up)

Full Weekday Early Education (School day hours only)

Half Day Early Education (4 hours per day)

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5. How many children between 3-6 years of age would be involved in a program?

How many children between 3-6 years of age would be involved in a program? 1

*
6. I'd like the Weekday Early Education Program to be?

I'd like the Weekday Early Education Program to be? Full Year (minus holidays)

School Calendar Year (according to local school)

Year Round School Calendar Year (based off a year round school calendar)

Other (please specify)

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7. What kind of child-care arrangements do you have now?

What kind of child-care arrangements do you have now?

*
8. If a Weekday Program was started, would you send your child/children?

If a Weekday Program was started, would you send your child/children? Yes

Comment/Explain

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9. What can you afford to pay for preschool services weekly and/or monthly?

What can you afford to pay for preschool services weekly and/or monthly?

*
10. Would you like to know the results of this survey and whether or not a weekday program will be opened?

Would you like to know the results of this survey and whether or not a weekday program will be opened? Yes

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Weekday Early Education ProgramExit this survey

1. Default Section

1. This information is not required, but would be useful for us to communicate with you if the Weekday program is started.

*2. Number of children in household:

*3. Are you working now?

*4. If weekday education services are offered, check the ones you would use.

*5. How many children between 3-6 years of age would be involved in a program?

*6. I'd like the Weekday Early Education Program to be?

*7. What kind of child-care arrangements do you have now?

*8. If a Weekday Program was started, would you send your child/children?

*9. What can you afford to pay for preschool services weekly and/or monthly?

*10. Would you like to know the results of this survey and whether or not a weekday program will be opened?