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Little Scholars Interest
Please complete the following survey to indicate your interest in Little Scholars.
Contact Information
Name
*
First Name
Last Name
Email
*
Verify Email
*
Address
*
Address Line 1
Address Line 2
City
City
State
State/Province
ZIP/Postal Code
Are you a MOMentum Network member?
*
Please select one of the following choices. We prioritize MOMentum Network members & prospective members in order to further our mission.
select one
Mom On Campus member
Alumni
Single Mom in College (not a member yet)
Staff
Village Volunteer (registered)
None of the Above
School &/or Employer
*
Phone
*
Child(ren) Name(s) & Birthdates
*
Please enter the name(s) of the child(ren) needing care, and their birthdates.
Is your child currently enrolled in care?
*
Please select "yes" or "no" reflecting if your child is currently enrolled for care at another facility. If the answer is yes, please indicate your reason for leaving.
select one
Yes
No
Do you currrently receive state assistance for childcare payments?
If you receive assistance from a program like Smart Steps or Families First, please select "yes." We may prioritize a percentage of assistance recipients in order to further our mission.
select one
Yes
No
Prefer not to say
Why are you interested in enrolling your child(ren) at Little Scholars?
Please indicate why you are searching for a new facility.
Work Hours
*
Put 0 if you are not currently employed
School Hours
*
Put 0 if you are not currently enrolled in college
How soon do you need care?
*
Additional Questions/Comments