1. Do you have a child that has any special needs or disabilities?  Yes No

If yes, please list the type(s) of special needs or disabilities:

If yes, please choose the types of accommodations and/or services your child would need:
(Hold the control button to choose multiple answers / please specify "other" in the comments section)
Requires regular medication Has food allergies and/or special diet Needs assistance in toileting Utilizes physical adaptive equipment Engages in agressive or violent behaviors Has seizures or history of seizures Has visual or hearing impairment Is nonverbal or has limited communication Requires 1 on 1 supervision Other

If yes, does your child currently attend a day care? Yes No

2. Which type(s) of child care would you need?
(Hold the control button to choose multiple answers)
Full Time (All day 5 days/week) Partial Week (All day 2 or 3 times/week) Half Days (5 days/week) Half Days (2 or 3 times/week) After School Care Night or Evening Care Weekends

3. What is your interest level in a special needs child care service?
Not Interested Somewhat Interested Interested Very Interested

4. What do you feel is a reasonable cost for these child care services?
$20 - $40 per day $40 - $60 per day $60 - $80 per day $80 - $100 per day

If you would like to be contacted when/if this special needs child care service is available,
please fill out the following information:
Name:
Phone:
Email: 

Additional Comments: