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The information you provide on
this page will be used to report aggregate demographic data to our funders. Individual
client data is kept confidential. You may be contacted by Starting Point for voluntary client
satisfaction feedback. Contact will be made by email, postal mail or telephone depending
on the contact information you provide. Starting Point does not share or sell mailing lists or
client names. |
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Name: |
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Contact
Method:
(If necessary, how can Starting Point contact you?)
(see note above regarding our privacy policy)
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Home Address:
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Daytime Phone:
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Email:
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County
of Residence:
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Age(s)
of Child(ren) at the Time Care is Needed:
(check all that apply)
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Number of children needing
care: |
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Reason
for Needing Care:
(check all that apply)
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Schedule:
(check all that apply)
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Response to the following questions is optional: |
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Employer:
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Household Income:
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Household Size:
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Single Parent:
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yes
no
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Spanish/Hispanic/Latino:
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yes
no
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Race:
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If other, enter here:
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Comments or special instructions: |
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