* 1. How many of your children are in each of the following age groups:

* 2. What is your annual family income before taxes are deducted? ( mark one)
*** Note: All information you provide is anonymous and will be used only as part of this child care survey. Information about family incomes in our community will be extremely useful to the child care committee but it is, of course, optional for you to provide it.**

* 3. What is your general pattern of need for child care? ( Please check the months and the days that you need child care)

* 4. Provide more details if necessary (e.g. if your care needs are irregular or you work shift)

* 5. If you have children in school, do you make special arrangements for no school Holidays, (Thanksgiving, Christmas Break, Spring Break)

* 6. Special arrangements

* 7. The committee is making great progress toward achieving our goal of opening a child care center in Hugo. There is still plenty that needs to be done and we are always looking for more people to help. If you would like to be part of the committee please fill out the information below: with your NAME and EMAIL