Counselors At Home Family Interest Form: LA County
To be introduced to other families who are looking to form a Pod and/or to be notified when new Counselors become available in your area that match your family's needs, please fill out this form.
Parent / Guardian First and Last Name *
Parent / Guardian Email Address *
Parent / Guardian Phone Number
Home Zip Code (5-Digit) *
Anticipated Usage
How often do you anticipate using this service between now and the end of the year, and do you need full-day or half-day care?
I need Full-Day Care (8-hours) Regularly
I need Full-Day Care (8-hours) Occasionally
I need Afternoon Care (4-hours) Regularly
I need Afternoon Care (4-hours) Occasionally
I need Morning Care (4-hours) Regularly
I need Morning Care (4-hours) Occasionally
My needs vary
Clear selection
Do you have any specific needs or requirements for your Counselor?
Would you like to be introduced to other families in your area who are looking to form a Pod? *
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