Child Care Survey

First Name

Last Name

Home Address

Street 1 Street 2 City State Zip

Email Address*

Cell Phone () -

1. Do you have children in your household under the age of 5?

Yes

No

2. Are the children in your household in daycare?

Yes

No

Number of Days per week?

Full days or Part Time?

Full days

Part time

Daycare Center or Home-Based?

Daycare Center

Home-Based

3. Do they attend pre-K?

Yes

No

4. On a Scale of 1 to 10, with 10 being the most difficult, how hard is it to find childcare?

5. How far are you driving for childcare?

6. On a Scale of 1 to 10, with 10 being high cost, how affordable is daycare?

7. If comfortable, please share how much you are paying per week, per child.

8. Do you receive any subsidy for childcare?

Yes

No

9. If receiving a subsidy, which program?

10. Does your employer offer any childcare benefits?

Yes

No

If so, what benefit?

Would you like to receive email updates from Senator Fowler?

YesNo

Would you like to sign up to receive occasional text messages from Senator Fowler? You can opt out at any time.**

YesNo