Special Needs Before/After School Care

Child's Name
MM slash DD slash YYYY
Parent/Caregiver Name
Address
1. Do you currently have childcare outside school hours?
2. Do you currently work or go to school?
3. Would you seek employment or go to school if you had childcare available?
4. Does your child’s disability affect your ability to find childcare because of his/her behavior, communication, social deficits, mobility, or toileting
5. Is extra support (classroom teaching assistant, one-on-one assistant/paraprofessional) required for your child any time during the school day?
6. Would you be interested in sending your child to a before/after school program if it were designed for individuals with disabilities?
7. Do you have more than one child with special needs?
8. Have you ever been released from a childcare provider?
9. Do you receive outside financial assistance? (home-based waiver, SSI, SSDI, child care assistance program, respite, DRS, SNAP, Medicaid)
10. Would you sign your child up for a before/after school program designed to support children with low to moderate disabilities?

11. If YES, what days/times would you need childcare?

Please select options for before and/or after for each day.