Central Arkansas Development Council Early Head Start Target Area Survey

1. Last Name *This question is required.

2. Phone Number *This question is required.

3. Address *This question is required.

4. City *This question is required.

5. State *This question is required.

6. Zip Code *This question is required.

7. County *This question is required.

8. Family Size (Number of people living in home who the Head of Household financially supports) *This question is required.

9. What is your families yearly income: (Get this from any of the following: 2021 Tax Returns Form 1040, W2 for 2021, etc...) *This question is required.

10. Does anyone in your family receive SSI (Supplemental Security Income) or TANF (Temporary Assistants for Needy Families)? *This question is required.

11. Number of children in your family between the ages of 6 weeks old up to 3 years of age?
*This question is required.

12. Is there anyone in your household currently pregnant? *This question is required.

13. If Central Arkansas Development Council was to open a Early Head Start (infant/toddler) center in your area, would you be interested in sending your child? *This question is required.