Gateways to Early Childhood Programs - Family Survey

If you are interested in learning more about Early Childhood supports and services, please fill out this brief survey and someone from our staff will contact you. Please share information about your children that are birth to 5 years old. All information will be kept confidential. Thank you!

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* 1. Parent First Name

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* 2. Parent Last Name

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* 3. Address (including city and zip code)

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* 4. Names and Birthdates of ALL children ages 5 and under in your family

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* 5. What Early Childhood services are you interested in learning more about?

Home Visiting (prenatal-3yrs)

Head Start (ages 3-5)

Preschool for All (half day ages 3-5)

Preschool Expansion (full day ages 4-5)

Child Care

Child Care Assistance Program

Early Intervention (ages 0-3, with concerns about child's development)

Developmental Screening (ages 0-5yrs)

Other (please specify)

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* 6. Phone Number

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* 7. Email

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* 8. I agree to have someone from SPARK program staff contact me by phone or email

Yes

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* 9. Our partners at the City of Aurora & The Neighbor Project have joined forces to launch Illinois’ first “Financial Empowerment Center” (FEC) to offer free, professional, one-on-one financial coaching as a public service to enable residents to address their financial challenges and needs while planning for their futures. Are you interested in learning more about this free service?

Yes

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* 10. Thank you for completing this survey. If you would like to speak to someone directly, please email us at spark@foxvalleyunitedway.org or call 630-896-4636 x109 or x112