Are you interested in a pre-K program? Please take a few minutes to complete our survey!

Name:
Address
City
State (select one)	ALABAMA AL ALASKA AK AMERICAN SAMOA AS ARIZONA AZ ARKANSAS AR CALIFORNIA CA COLORADO CO CONNECTICUT CT DELAWARE DE DISTRICT OF COLUMBIA DC FEDERATED STATES OF MICRONESIA FM FLORIDA FL GEORGIA GA GUAM GU HAWAII HI IDAHO ID ILLINOIS IL INDIANA IN IOWA IA KANSAS KS KENTUCKY KY LOUISIANA LA MAINE ME MARSHALL ISLANDS MH MARYLAND MD MASSACHUSETTS MA MICHIGAN MI MINNESOTA MN MISSISSIPPI MS MISSOURI MO MONTANA MT NEBRASKA NE NEVADA NV NEW HAMPSHIRE NH NEW JERSEY NJ NEW MEXICO NM NEW YORK NY NORTH CAROLINA NC NORTH DAKOTA ND NORTHERN MARIANA ISLANDS MP OHIO OH OKLAHOMA OK OREGON OR PALAU PW PENNSYLVANIA PA PUERTO RICO PR RHODE ISLAND RI SOUTH CAROLINA SC SOUTH DAKOTA SD TENNESSEE TN TEXAS TX UTAH UT VERMONT VT VIRGIN ISLANDS VI VIRGINIA VA WASHINGTON WA WEST VIRGINIA WV WISCONSIN WI WYOMING WY Armed Forces Africa AE Armed Forces Americas AA (except Canada) Armed Forces Canada AE Armed Forces Europe AE Armed Forces Middle East AE Armed Forces Pacific AP
Phone # (XXX)XXX-XXXX
Email Address:
I have a child who will be 4 years old by 9/30/2010	Yes No
I have a child who will be 4 years old by 9/30/2011	Yes No
I have older children and us a a Pre-K program elsewhere	Yes No
If YES, please provide name of Pre-K program
I am interested in enrollying my child in a Pre-K program for the 2010-2011 academic year	Yes No
I am interested in enrolling my child in a Pre-K program for the 2011-2012 academic year	Yes No
I am looking for a:	Half-Day Pre-K Program Full-Day Pre-K Program
I would use one of the following options for for full-day Pre-K child	Before School Program After School Program Both Before and After School Program
I have a child/ren under the age of four	Yes No
When my child is eligible for a 4 year old program, I would be interested in a Pre-K program at infant Jesus	Yes No
In order to expand our interest for a Pre-K program, please share any name of prospective families who might be interested in a Pre-K program

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