After School Needs Assessment

To understand household child care needs this assesment is created. If you have parenting responsibilities, please complete this form.

We appreciate your time in helping us assess your needs.

Please mark the type of After School care you are currently utilizing.

Which ones do you think that prevents you from using the service?

Please indicate your household gross salary range

Number of People in your household

Please List All the People in Your Household

Approximately what time does an adult get home after school hours?

Hour Minutes

AM/PM Option

What would be the amount you consider reasonable to pay for school-age child care PER MONTH/PER CHILD?

Which child care related problems have you faced during the past year?

Where do your children attend school at?

Street Address

Street Address Line 2

CityState / Province

Additional Notes

Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.