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* 1. What is your zip code

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* 2. How many children under the age of five live in your home?

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* 3. What ages are your children? (Check all that apply)

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* 4. Do you have a child with a disability? Individual Family Service Plan (IFSP) OR Individual Education Plan (IEP)

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* 5. Please check all of the types of early learning programs your child/children birth to 5 years old participate in on a regular basis.

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* 6. If you  have a preschool child (child age 3, 4, or 5 years old) who does not currently attend an early education program, please indicate why. (Check all that apply)

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* 7. Do you have enough information to locate early education and care programs that will meet your family’s preference and needs?

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* 8. I am interested in participating in the following types of activities to foster my child's development. (check all that apply)

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