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Child Care Needs for Families
1.
What is your zip code?
2.
How many people currently live in your household?
3.
What are the ages of the child/children living in the home?
4.
Do any of the children living in the home receive supports/services?
Yes
No
If yes, please explain
5.
Do you have any concerns about your child/children?
Communication
Navigating a playground
Using a crayon or feeding themselves with utensils
Playing well with others
Problem Solving
Please use this section to add any concerns not listed above or provide additional information.
6.
What is the primary language spoken in the home?
7.
Does any member of the household have reliable transportation to and from childcare?
Yes
No
Does anyone commute? If yes, where?
8.
What hours do you generally need for childcare? Check all that apply.
Full Time
Part Time
Drop In
Overnight
Weekends
Other (please specify)
9.
Is it a necessity for your family to have assistance paying for childcare?
Yes
No
Sometimes
Other (please specify)
10.
What are the top three (3) things you look for when considering childcare?
Cost
Safety
Reputation of caregiver or center
Location
Cleanliness
Food included
Ages served
Accepts subsidies/scholarships
Support for behavior issues
Available transportation
Provider does NOT transport children
Kindergarten preparedness
Social skills
In home care
Center based care
Other (please specify)
Thank you for your time and feedback.
