Name:           

Address        

City, ST ZIP  

Home Phone #            Work Phone #   

Email Address    

How did you get your job?     Agency Newspaper Word of mouth Other....   If Agency, which one?   

How many children do you care for?  1 2 3 4 More than 4

Names and ages 

City you work in? 

Would you be interested in a play group in your area?  Yes  No

Would you be interested in hosting a play group in your area?  Yes  No

Are there any speakers you would like to see at our meetings?  Yes  No

                                                        If Yes

What is a good time for our meetings?  Evening Week Evening Weekend Day Weekend  

Best time?     Best day?

What would you like to see in our Newsletter?

Would you like to be on a phone list published for nannies?  Yes  No

Would you like to be on our email mailings?    Yes  No

Please give us your opinions and Comments: