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* 1. Which EPBGC location does your child(ren) usually attend?

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* 2. Do you need childcare this summer?

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* 3. When do you wish your child to start?

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* 4. How many school-aged children do you have that need care this summer?

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* 5. What are their ages (check all that apply)

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* 6. What time do you wish to drop off your child?

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* 7. What time will you be picking your children up?

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* 8. Do you currently receive CCAP/childcare assistance from DHS?

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* 9. What are your child's interests? (Check all that apply)

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* 10. Will your child have distance learning needs in June?

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* 11. Are you interested in having your child participate in fun summer learning activities this summer?

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* 12. Contact Information

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