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Request for Assistance Application
Contact information is needed to contact those that are selected to receive assistance.
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* Indicates required question
First Name:
*
Your answer
Last Name:
*
Your answer
Address (City / State / Zip / County)
*
Your answer
Business Name:
*
Your answer
Provider #:
*
Your answer
Date Of Birth:
*
MM
/
DD
/
YYYY
Email
*
Your answer
Phone number
*
Your answer
Emergency Assistance Service Needed?
*
Utility Assistance and Shut-off Prevention
Move-in Assistance
Rental Assistance and Eviction Prevention
Child Care Provider Supplies
Other:
Required
Please describe in detail what you are requesting, and the amount needed as well
*
Your answer
How has Covid-19 affected your business?(Select all that apply)
*
I had to close down my business due to state regulations
I had to close down my business due to a lack of clients
I have less clients due to Covid-19
I had to reduce my capacity due to state regulations
Required
What are your biggest challenges for your business right now?
*
Your answer
Do you feel that the state has been supportive to daycare business during this Covid-19 pandemic?
*
Your answer
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