Family Questionnaire

Family Name_______________________________________

Child Name____________________________________________Age______________

Email_____________________________________________Phone________________

Choose one or both:

• Desired Start Date____________________________________

• Desired Test Drive_____________________________________

How did you hear about us?

• Website
• Facebook
• Twitter
• Instagram
• Referral ____________________________________

What type of childcare setting has your child experienced?

• Center
• Family Home
• Parents, Family, Friends
• Nanny/Sitter
• First Time in Childcare

If you are coming from another type of childcare what is the reason for leaving?

• Cost
• Moving
• Bad Childcare Experience (circle all that apply: multiple sickness, accidents, bad provider interaction, high student/teacher ratio, curriculum lacking or missing, not enough structure, too much structure, no outside time, too much outside time, better hours, not clean enough, ect______________________________________________________________)

Best Date for Tour

• Wednesday (5:30, 6:00, 6:30)
• Thursday (5:30, 6:00, 6:30)
• Weekend by Special Arrangement (4:00, 5:00)