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Wee Care Center Intake Information
Questions 1 - 14 are about YOU
1.
What is your name?
2.
What is your home address?
3.
What is your phone number?
4.
What is your e-mail address?
5.
Where do you work?
6.
What is your hourly wage?
7.
How many hours a week do you work?
8.
What days do you typically work>
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
9.
What shift do you work?
Day shift (7 am - 3 pm)
Second shift (3 pm - 11 pm)
Third shift (11 pm - 7 am)
Other (please specify)
10.
How often do you get paid?
Weekly
Every other week
Twice a month
Monthly
11.
Do you go to school?
Yes
No (skip to question #14)
12.
Where do you go to school?
13.
How do you attend school?
In person only
On-line only
Both in person and on-line
14.
What are you working toward?
Certificate (CNA, welding, etc)
Associate's Degree
Bachelor's Degree
Master's Degree
Other (please specify)