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* 1. Would you use child care services if they were available to you?

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* 2. Are you currently using child care services?

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* 3. Identify the type of services you use by age range

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* 4. Please mark the type of child care needed

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* 5. Please mark the location/type of care you are currently utilizing

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* 6. Are you satisfied with your current child care arrangements?

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* 7. If you do not utilize child care services, what prevents you from using services?

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* 8. To help assess funding needs, please indicate your household gross salary range

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* 9. Is your household headed by a two-parent household or a single parent household?

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* 10. How many children do you have in each of the following age groups

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* 11. Which care would you PREFER?

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* 12. Please check the days you need child care. Check all that apply

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* 13. Please check the times you need school-age child care. Check all that apply

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* 14. Please check the amount you consider reasonable to pay for child care PER MONTH/WEEK/PER CHILD during the regular school year. Check only one

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* 15. Have you had any of these child care related problems during the past year?

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