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COVID 19 Childcare Assistance
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1.
Are you considered an essential employee that is required to work during the COVID 19 Pandemic?
(Required.)
Yes
No
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2.
Do you have children below the age of 12 that require childcare?
(Required.)
Yes
No
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3.
Do you currently have your childcare needs met?
(Required.)
Yes
No
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4.
If you had an alternate means of childcare available, would you pay a minimal fee to use it?
(Required.)
Yes
No
Other (please specify)
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5.
What are the age ranges of your children? Please check all that apply.
(Required.)
Newborn - 1 1/2 years
1 1/2 years - 3 years
3 years - 5 years
5 years - 8 years
8 years - 12 years
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6.
What shift do currently work and would need childcare to cover? Check all that apply.
(Required.)
Day shift
Evening shift
Night shift
Weekends
Other (please specify)
7.
Do you have any other comments that would help us better address childcare needs for essential workers?
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8.
What locality do you reside in currently?
(Required.)
Buchanan
Dickenson
Russell
Tazewell
Lee
Scott
Wise
City of Norton
Other (please specify)