After School Needs Assessment Form

Name

Phone number

Email

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

• Day Care Center

• Family Care Center

• Provider in my home

• Spouse/Partner

• Care by family members

• After School Program

• Care by older sibling

• Not utilizing any After School care

Which one prevents you from utilizing the service?

• Availability

• Location

• Hours of Operation

• Happy with current provider

• Transportation

Please indicate your household gross salary

• Less than $20,000

• $20,000 - $29,000

• $30,000 - $ 39,000

• $40,000 - $ 49,000

• $50,000 - $59,000

• More than $60,000

Number of People in your household

Role

• Child

• Adult

• Elder

Age

Date of Birth

Need Childcare?

Which Days if Childcare needed

• Monday

• Tuesday

• Wednesday

• Thursday

• Friday

• Saturday

• Sunday

When Childcare needed

• Before School

• After School

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

What would be the amount you consider reasonable to pay for school-age child care per month/per child?

What childcare-related problems have you faced during the past year?

• Cost of Care

• Finding Temporary Care

• Finding Care for a child with special needs

• Location of care

• Transportation to/from care

• Dependability of care

• No issues