Louisiana’s 2nd Day Without Child Care Business Sign Up Form
Business/Organization Name
*
Your Name
*
First Name
Last Name
Job Title
*
Business/Organization Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What Parish is the Business/Organization located in?
*
Email Address (for updates and event details)
*
example@example.com
Cell Phone Number (for text reminders)
*
-
Area Code
Phone Number
How many employees rely on child care to work?
*
How does child care impact your daily life? (Short open-ended response, e.g., “I can go to work because I have child care.”)
*
Would you like to provide a statement on why your business supports child care? (Optional, open text field – Example: “Our business is open today because [XX] employees have child care.”)
*
Would you like to be publicly listed as a supporter of this campaign? (Yes/No)
*
Yes
No
How else would you like to take action? (Select all that apply)
*
Sign our business pledge supporting child care investment.
Display a sign in our business to show our support.
Share our support on social media using #DayWithoutChildCare and other hashtags.
Allow employees time off to attend the rally at the Capitol.
Provide a quote or testimonial about how child care affects our business.
Other
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