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YWCA Cares Program Information Form
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YWCA Cares Program Information Form
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YWCA Cares Program Information Form
YWCA knows many families are experiencing difficulty finding and affording childcare for infants, toddlers, and school-age children during COVID-19. The YWCA Cares program aims to provide no-cost childcare to families in need for a variety of reasons. This form will assist Team YWCA in determining family needs and how we can support you.
Name/Nombre
*
First
Last
Address/Su dirección
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Phone/Número de teléfono
*
Email/Correo electrónico
*
Are you an employee of the City of El Paso?/¿Trabaja para la ciudad de El Paso?
*
Yes
No
Do you reside within El Paso city limits?/¿Vives en los límites de la ciudad de El Paso?
*
Yes
No
Are you any of the following?/¿Usted es alguno de los siguientes?
*
A veteran currently living in Texas/Un veterano que vive en Texas
Pharmacy or healthcare worker/Trabajador de farmacia o sanitario
Local or state government worker/Trabajador del gobierno local o estatal
Restaurant or food delivery worker/Trabajador de restaurante o repartidor de comida
First responder/Primer respondedor
Gas station employee/Empleado de la gasolinera
Childcare/home health provider, or other caregiver / Proveedor de cuidado de niños / salud en el hogar u otro cuidador
Mail/delivery worker / Trabajador de correo/entrega
Military personnel/Personal militar
None of the above/Ninguna de las anteriores
How many children between the ages of 0-12 currently live with you? Please list their ages. / ¿Cuántos niños de 0 a 12 años viven actualmente con usted? Indique sus edades.
*
How did you hear about the YWCA Cares Program? (Select all that apply)/¿Cómo se enteró del Programa Cares de la YWCA? (Seleccione todas las que correspondan)
*
Social media/Redes sociales
News media/Noticias
Email/Correo electrónico
Moms on Board
Word of mouth (friend, family, etc.)/El boca a boca (amigo, familia, etc.)
Received notice in the mail/Aviso en el correo
Radio commercial/Comercial de radio
Employer/Empleador
Flier/El folleto
TV commercial/Comercial de televisión
Other/De otra manera