Name: ___________________________________

Address: _________________________________

Phone # ____________________________

Age: _______

What are the first names and ages of your children?

Name >>>>>>>>>>>>>>>>>>>>>>Age
__________________________________________
__________________________________________
__________________________________________
__________________________________________
__________________________________________

Do you work outside the home? __Yes __No

If yes, do you work full-time or part-time? __ Full-time __ Part-time

How many are in your household? ________________

About how much income does your family have? (Fill in any of the following)
An hour________________ a week _________________
A month________________ a year____________________

Are any of your children in day care while you work or go to school?

__ Yes __ No

If yes, please check the types of care you have for your children.

What is the total amount of money that you spend for day care for your children?
(Fill in either of the following.)

Weekly ____________ Monthly ____________

Did you know that some working parents can get help to pay for certain types of day care?
__ Yes __ No

Are you getting help from any program in paying for day care? __ Yes __ No

Do you have health insurance for any of your children? __ Yes __ No

Have you heard about a child health insurance program for those who don’t qualify for Medicaid called CMSIP (pronounced “simsip”)? __ Yes __ No

If yes, are your children on CMSIP? __ Yes __ No __ Don’t Know

Are your children on Medicaid? __ Yes __ No __Don’t Know

Would you like a copy of the report about these meetings sent to you? __ Yes __ No

Thank you for your time!

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