Safer At Home Child Care Needs Assessment

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This form is to help the Luck School District and The Nest At Butternut Crossing determine the level of need for child care services for essential workers during Governor Ever's Safer At Home order. To see the specifics of this order, please to go: https://evers.wi.gov/Documents/COVID19/Safer%20at%20Home%20FAQ%203.24.20.pdf

Please note:
-You do not need to be a resident of Luck or reside within the Luck School District to complete this survey.
-This survey is not an agreement for services.
-A letter of verification from your employer will be required for any services to be provided.

Email *

Name: *

Zip Code *

What is your resident school district? *

How far is your residence from Luck School? *

How far is your place of employment from Luck School? *

How many children, ages birth to 12, are in your home? *

Current employment status and child care need: *

I am an employee, contractor, or other support staff working in health care, and need child care (please complete the family information below)

I am considered an employee, contractor, or staff of an essential business, and need child care services during this time (please complete the family information below)

I am an essential employee, but currently do not need child care services

I am a non-essential employee, and currently do not need and child care services

Employer and occupation/position *

Name(s) and age(s) of child/children

Days and hours of care needed

Desired start date of care

YYYY

Telephone number (if you would like us to contact you)

Send me a copy of my responses.

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