FRC Program Registration Survey

FRC Program Registration

Please enter the people in your family that will participate in the program on this page. Please enter adult and children in the appropriate areas by entering the full name of each participant. If more than 7 participants will be attending please include them in the comments section at the end.

1. Participant(s):

Participant(s): Adult's Name:
Adult's Name:
Adult's Name:
Child's Name & Age:
Child's Name & Age:
Child's Name & Age:
Child's Name & Age:

2. Do any of the participants require accommodations?

Do any of the participants require accommodations? No

Yes

If yes, please specify.

3. All of the above participants are registering for the following program(s).

All of the above participants are registering for the following program(s). Military Families Connect Support Group - Monthly

Love and Logic for Elementary Parents - 2/1, 2/8, 2/15, 2/22/2010

As One - 2/2, 2/4, 2/9, 2/11/2010

Baby Sign (6-18 mos) - 2/10, 2/17/2010

Family Voices - 2/13, 2/20/2010

Parenting Terrific Toddlers - 2/23/2010

He Said, She Said - 3/10/2010

1-2-3 Magic - 3/8, 3/15/2010

Open Gym @ Northview Elementary - 3/13/2010

Kids Nutrition Corner - 3/18/2010

Tea for Two - 3/23/2010

Sweet Embraceable You - 4/12, 4/19, 4/26/2010

Dad and Me Visit the Firehouse - 4/14/2010

Boys Boys Boys - 5/5/2010

As One - 5/4, 5/6, 5/11, 5/13/2010

The Tooth, The Whole Tooth and Nothing But The Tooth - 5/17/2010

Kids Nutrition Corner - 5/18/2010

Once Upon a Potty - 5/24/2010

4. Please enter your contact information here.

Please enter your contact information here. Address:
Address 2:
City/Town:
State:
ZIP/Postal Code:
Email Address:
Phone Number:

5. How would you like to receive your confirmation?

How would you like to receive your confirmation? Email

Phone

6. Would you like to receive email updates from the Family Resource Center?

Would you like to receive email updates from the Family Resource Center? Yes

7. How did you hear about the program(s)?

How did you hear about the program(s)? Counselor/Clergy TV/Radio/Newspaper County Health Dept. Website/Internet Health Care Provider	School Staff Brochure Prenatal/Birthing Class Friend/Relative Information & Referral Hotline	Flyer/Catalog Dept of Health & Human Services FRC Staff Other
Other (please specify)

8. If the above participants will not be attending all of the programs selected above, please indicate who will attend each program.

If the above participants will not be attending all of the programs selected above, please indicate who will attend each program.

9. How would you rate today's online registration experience.

	Yes	No
Registering online was convenient.	How would you rate today's online registration experience. Registering online was convenient. Yes	No
I would register online again.	I would register online again. Yes	No
Registering online was easy.	Registering online was easy. Yes	No

10. Additional comments:

Additional comments:

1. Participants