Mixed Delivery Program: Family Screener Form

Who can complete this form? Families can complete this form. Early childhood program staff can also complete this form, in collaboration with families.


Is there a residency requirement? Parent or Guardian and child must be residents of Virginia.


The information submitted here is kept confidential and safely maintained. Your responses are used to determine probable child eligibility, add child to child care waitlists, and support enrollment in a child care program. Children on the waitlist will fill slots as they become available. The Mixed Delivery Specialist or early childhood program staff will contact the family.


To complete this survey in another language:

  1. Right-click anywhere on this page.
  2. Select "Translate to...".
  3. At the top of the page, choose your preferred language.
  4. Click "Translate" or "Done".
  5. Questions will appear in the language selected.
  6. Complete form and SUBMIT.


Disclaimer: This form will be translated through "machine translation" powered by Google Translate. As with any machine translation, the conversion is not context-sensitive and may not fully convert text into its intended meaning. Disclaimer.


For support or questions, contact, NCSMD-RRCA@fairfaxcounty.gov