Family Interest Survey

Family Interest Survey-Before and After Care Program

EAOLM is gathering information from Families interested in before-and after-program care for adults with intellectual and developmental disabilities. Your responses will help us to determine community demand, service hours, transportation needs, and future development

Parent/Guardian Name

Phone

Email

Current Program or school type

When would you need services to begin ?

Morning care need?

YES

NO

After Care Needed?

YES

NO

Transportation Needed?

YES

NO

Age of individual Needing Services

Expected Payment/Funding Type

When would you need services to begin ?

Would you like EAOLM to contact you when services are available?

YES

NO

Days of the week needed and approximant hours

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Approximate Hours Needed

Additional Comments

Thank you!

We have received your submission.

Error

Bad respond

Disclaimer: This form is an expression of interest only. Completing this survey does not constitute enrollment or guarantee services. Please do not submit Social Security numbers, Medicaid identification numbers, detailed medical records, or other sensitive health information through this form