Safer At Home Child Care Needs Assessment
This form is to help the Luck School District and The Nest At Butternut Crossing determine the level of need for child care services for essential workers during Governor Ever's Safer At Home order. To see the specifics of this order, please to go: https://evers.wi.gov/Documents/COVID19/Safer%20at%20Home%20FAQ%203.24.20.pdf

Please note:
-You do not need to be a resident of Luck or reside within the Luck School District to complete this survey.
-This survey is not an agreement for services.
-A letter of verification from your employer will be required for any services to be provided.
Email address *
Name: *
Your answer
Zip Code *
Your answer
What is your resident school district? *
Your answer
How far is your residence from Luck School? *
Your answer
How far is your place of employment from Luck School? *
Your answer
How many children, ages birth to 12, are in your home? *
Your answer
Current employment status and child care need: *
Employer and occupation/position *
Your answer
Name(s) and age(s) of child/children
Your answer
Days and hours of care needed
Your answer
Desired start date of care
MM
/
DD
/
YYYY
Telephone number (if you would like us to contact you)
Your answer
Submit
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