Child Care Facilitated Enrollment Pre-Screening Questionnaire
Please complete the following questionnaire and one of our staff members will get back to you as soon as possible to complete your pre-screeing process.

Please note that this is NOT an application for the Child Care Facilitated Enrollment Project.

Last Name: *
Your answer
First Name: *
Your answer
Street Address: *
Your answer
Borough: *
Home Zip Code: *
Your answer
Home/Cell Phone: *
Your answer
Work Phone:
Your answer
Email: *
Your answer
How did you hear about us?: *
Your answer
Are you a union member?: *
If you answered yes, which union & local?
Your answer
Are you currently employed? *
What is your annual (gross) income? *
Your answer
How many hours do you work per week? *
Your answer
What is your employer's name? *
Your answer
What is your employer's address? *
Your answer
Employer's borough: *
Employer's Zip Code: *
Your answer
What is your job title? *
Your answer
Do you receive any other income, such as disability benefits/child support? *
If you indicated yes to the question above please indicate what other income you receive.
Your answer
Please indicate the amount of other income you receive.
Your answer
Do you live with a spouse? *
If you indicated yes to the question above please indicate your spouse's income:
Your answer
Does your spouse receive any other income, such as disability benefits/child support? *
If you indicated yes to the question above please indicate what other income your spouse receives?
Your answer
Please indicate the amount of other income your spouse receives.
Your answer
How many children reside in your home? *
Your answer
What are their ages? *
Your answer
Are you currently receiving a subsidy for any of the children in your household? *
Do you want to be contacted about additional opportunities to apply for child care funding through New York City’s Administration for Children’s Services? *
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