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* 1. What is your first and last name?

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* 2. In what ZIP code is your home located? (enter 5-digit ZIP code; for example, 11222 or 10001)

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* 3. E-mail

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* 4. What is your primary NYSNA Facility?

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* 5. What type of facility do you work in?

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* 6. What shift do you work?

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* 7. Do you currently participate in the NYSNA Child Care Fund?

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* 8. Are you the primary caregiver for children that are school age? (Preschool - Grade 12)

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* 9. How many children are you parent or guardian for and live in your household (aged 17 or younger only)?

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* 10. How many children total will require child care?

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* 11. For each child, please select their grade level and school type

  Grade level School Type
Child 1
Child 2
Child 3
Child 4
Child 5
Child 6

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* 12. Schools may close in response to COVID-19, do you have a plan for child care if the schools close?

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* 13. If your child is in daycare, do you have a plan for child care if your daycare provider closes?

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* 14. If financial support were available, which option would best fit your child care needs?

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* 15. What days would you need child care? (Please select all that apply)

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* 16. What times would you need child care?

Time
Time
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