Child Care Facilitated Enrollment Pre-Screening Questionnaire
Complete this form to be placed on the waitlist for the Child Care Facilitated Enrollment Project - a program that helps working families pay for child care and after-school expenses. We are currently processing a high volume of pre-screening requests and will reach out to you to complete your pre-screening process as soon as we are able.  There is no standard amount of time to be on the waitlist.

Please note that this is NOT an application for the Child Care Facilitated Enrollment Project.
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Last Name: *
First Name: *
Street Address: *
Borough: *
Home Zip Code: *
Home/Cell Phone: *
Work Phone:
Email: *
How did you hear about us?: *
Are you a union member?: *
If you answered yes, which union & local?
Are you currently employed? *
What is your annual (gross) income? *
How many hours do you work per week? *
What is your employer's name? *
What is your employer's address? *
Employer's borough: *
Employer's Zip Code: *
What is your job title? *
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.
Please indicate the amount of other income you receive.
Do you live with a spouse? *
If you indicated yes to the question above please indicate your spouse's income:
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?
Please indicate the amount of other income your spouse receives.
How many children reside in your home? *
What are their ages? *
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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