Child Care Needs for Families Question Title * 1. What is your zip code? Question Title * 2. How many people currently live in your household? Question Title * 3. What are the ages of the child/children living in the home? Question Title * 4. Do any of the children living in the home receive supports/services? Yes No If yes, please explain Question Title * 5. Do you have any concerns about your child/children? Communication Navigating a playground Using a crayon or feeding themselves with utensils Playing well with others Problem Solving Please use this section to add any concerns not listed above or provide additional information. Question Title * 6. What is the primary language spoken in the home? Question Title * 7. Does any member of the household have reliable transportation to and from childcare? Yes No Does anyone commute? If yes, where? Question Title * 8. What hours do you generally need for childcare? Check all that apply. Full Time Part Time Drop In Overnight Weekends Other (please specify) Question Title * 9. Is it a necessity for your family to have assistance paying for childcare? Yes No Sometimes Other (please specify) Question Title * 10. What are the top three (3) things you look for when considering childcare? Cost Safety Reputation of caregiver or center Location Cleanliness Food included Ages served Accepts subsidies/scholarships Support for behavior issues Available transportation Provider does NOT transport children Kindergarten preparedness Social skills In home care Center based care Other (please specify) Thank you for your time and feedback. Done
