Thank you for completing this form. This will help us as we make the case to reimburse any net loss you and other providers incurred from providing childcare during the early months of the COVID-19 pandemic. 

All questions below refer to childcare services provided between March 15, 2020 to June 19, 2020.

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* 1. Respondent Name:

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* 2. Organization Name:

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* 3. Email address:

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* 4. Please enter the number of sites operated by your organization that provided school age childcare between 3/15/2020 and 6/19/2020.

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* 5. Number of children ages 0-5 (pre-K) served by these sites during this period.

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* 6. Number of children ages 5-12 served by these sites during this period.

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* 7. Total expenses incurred by providing childcare at these open sites during this period.

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* 8. Total revenue received for providing childcare during this period (include program fees/private pay, subsidy and/or other program revenue).

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* 9. Anything else that we should know as we advocate for these funds?

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