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Name: ________________ Phone Number: _________________

Address: ________________ Cell Phone: __________________

City: ________________ E-Mail: __________________________

Comments: _____________________________________________

Please fill in the forms and hand in with your $20 DKV Annual Membership Fee… In order to join our Society, you need to fill out a one-page survey. You can also just fill out a survey without joining the Society. All membership money will go towards the Society.

You can print out this page and fill out the survey and send it to us through an e-mail or "snail-mail". 1573 East 18th Street, Vancouver, BC c/o of St. Mark's Evangelical Lutheran Church.

1. Would you use German childcare services if they were available to you?

YES OR NO

2. Please describe your child’s cultural heritage: (circle)

Both mother & father are german (swiss, Austrian)
Mother or father have some german heritage
Mother was born in Germany
Father was born in Germany
No one at home speaks german

3. Please mark the type of child care you would most likely need:

Full Time Daycare
Full Time Preschool (4 hours per day)
Partial Week (2 or 3 times/wk)
Preschool-Partial wk (2 or 3 times/wk)
After School Care

4.How MANY children do you have in each of the following age groups?

a.0-4 years old
b.5-8 years old
c.9-12 years old

5. Please check your preferred location:

a. Westend (downtown)
b. Westside
c. North Shore
d. Other: ___________________
e. I know a great location
f. I’ll help the Location Committee

6. Please check the days you would like child care. Check all that apply.

a. Monday-Friday
b. Two days a week
c. Three days a week
b. Weekends, holidays, summer breaks
c. Other

7. Please check the times you need school-age childcare. Check all that apply.

a. Before school only
b. After school only
c. Before and after school

8. Please check the amount you would be able to comfortably pay for child care PER MONTH during the regular school year. Check only one.

a. $ 60-99
b. $ 100-120
c. $ 121-149
d. $ 150-175
e. $ 176-199
f. Over $200

9.If you joined the DKV (Non-profit Board), which role would you prefer?

a. Fundraising Committee
b. Location Committee
c. Building Committee
d. Publicity & Media Relations
e. Membership
f. Fundraising Committee