Sullivan County Childcare Survey for Essential Personnel
The Sullivan County school districts are gathering information to ascertain if we have essential workers (essential workers include all workers in the areas listed in the second question of the survey) in our community who need assistance with childcare.  

Child Care services will be provided in the RISE Building at Catskill Regional Medical Center.  

Please fill out the questionnaire below if you believe you meet these criteria.    

This is a service by appointment program.  The hours of availability will be determined by the needs identified in this survey.  Do not drop your children off at the site until you are notified that the program coordinators.  

Each family will be required to complete a modified Day Care Enrollment form asking for emergency contact information and other pertinent information for each child. Forms will be sent directly to those indicating they require child care services via e-mail so that they can be completed in advance.
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My family requires childcare services *
Please identify the category that applies to you *
Please share the name of your employer or the organization you work for *
Please list the hours you require child care services *
Please share the day(s) of the week you require child care services *
Required
What date do you need childcare services to start? *
MM
/
DD
/
YYYY
Please complete this for all parents in the household:
Parent 1:
Parent 1: Please share your full name. *
Parent 1: Please share your address *
Please include your physical address, city and zip code
Parent 1: Please share your phone number. *
Parent 1: Please share your cell phone number. *
Parent 1: Please share your email address. *
What is the best way to contact you? *
Parent 2:
Parent 2: Please share your full name. *
Parent 2: Please share your address *
Please include your physical address, city and zip code
Parent 2: Please share your phone number. *
Parent 2: Please share your cell phone number. *
Parent 2: Please share your email address. *
What is the best way to contact you? *
Please list the names of your child(ren)
Please include first and last name.
Child #1 *
Please include the first and last name
Child #1 *
What is his or her age?
Child #2 *
Please include the first and last name
Child #2 *
What is his or her age?
Child #3
Please include the first and last name
Child #3
What is his or her age?
Child #4
Please include the first and last name
Child #4
What is his or her age?
Child #5
Please include the first and last name
Child #5
What is his or her age?
Child #6
Please include the first and last name
Child #6
What is his or her age?
Please list the types of activites your child(ren) enjoy *
What school district do you reside *
Required
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