Leesville R-IX Community Child Care/Preschool Needs Assessment Survey
This is an assessment of child care needs of the Leesville R-IX School District and surrounding community. If you have parenting responsibilities, we would appreciate your time in helping us assess your needs. Simply complete the survey no later than April 3, 2018, so we may assess the need for preschool services in our district. Thank you for assisting us with this effort.
Would you use child care and/or preschool services if they were available in this area?
If yes, please complete the remainder of the survey.
Your answer
Are you currently using child care services?
If yes, indicate the type of services you use
Children in Age Range
Infant (Birth to 11 months)
Toddler (11 to 36 months)
Preschool (3 to 5 years)
After School Care (K-6th grade)
After School Care (7-9th grade)
Please provide the cost per child for each age range indicated.
Your answer
Please mark the type of child care needed:
Check the type of child care are you currently using:
What is the location or distance you travel from home for child care?
Your answer
If you don’t utilize child care services, what prevents you from using services? (Check all that apply)
Please indicate how many family members live in the household.
Your answer
To help assess funding needs, please indicate your household gross salary range.
Is your household headed by a two-parent, single-parent, or multi-family household?
Please check one in each column for the type of care you USE and/or the type of care you PREFER.
Type of Care I USE MOST
Type I Would MOST Prefer
Care by parent in own home
Care in relative's home
Care in own home with relative
Care in own home with non-relative
Care in non-relative's home
Child care for self
Child Care Center
Combination of care as needed
Currently searching for care
School based program
Please check the days you need child care. Check all that apply.
Please check the times you need school-age childcare. Check all that apply.
Please check the amount you consider reasonable to pay for child care PER MONTH/PER CHILD during the regular school year.
Have you had any child care related problems during the past year?
If yes, please check problem areas:
If you are interested in serving on a Preschool Parent Advisory Board, please provide your name, cell number and email address.
Your answer
Never submit passwords through Google Forms.
This form was created inside of Leesville School District. Report Abuse - Terms of Service - Additional Terms