Safe Homes Parent Network of Franklin County VT Survey

Franklin County Caring Communities and GICCT invite you to be part of the “Safe Homes Parent Network” across Franklin and Grand Isle Counties. What is “Safe Homes Parent Network?” It’s a new way for parents to be supported in helping their kids to remain alcohol and drug free, and to connect with other families who have the same policies and goals. We’re inviting parents to “sign on” to the following:

1. Please note: The Safe Homes Parent Network commitment is not a legally binding contract, but rather an agreement between members of the SAFE HOMES Parent Network of Franklin County.

Please show your commitment by checking the boxes below. You may opt not to check the fourth box if you do not wish to share your contact informaiton:

Please note: The Safe Homes Parent Network commitment is not a legally binding contract, but rather an agreement between members of the SAFE HOMES Parent Network of Franklin County. Please show your commitment by checking the boxes below. You may opt not to check the fourth box if you do not wish to share your contact informaiton: I will actively supervise all gatherings of youth in our home or on our property, or ask another responsible adult for help to do so.

I will not allow the possession of alcohol, tobacco, or other drugs by youth in our home or on our property.

I will set expectations for my children by knowing where they are going, whom they are with, what they are doing, and when they are to return home.

I will welcome phone calls about activities taking place in my home and on my property.

2. Please complete the information below

Please complete the information below First Name:
Last Name:
Spouse First Name:
Spouse Last Name:
Address:
Town:
State:
Zip code:
Phone:
Cell phone:
Email:

3. We would like permission to publish your name as a member of the Safe Homes Parent Network of Franklin County in the Safe Homes directory. This directory will be made available to other parents/guardians who have joined the Safe Homes Parent Network. Please indicate below if we may do so.

We would like permission to publish your name as a member of the Safe Homes Parent Network of Franklin County in the Safe Homes directory. This directory will be made available to other parents/guardians who have joined the Safe Homes Parent Network. Please indicate below if we may do so. I GIVE PERMISSION to publish my NAME, TELEPHONE, EMAIL, AND TOWN.

I GIVE PERMISSION TO publish my NAME and TOWN ONLY.

I DO NOT give permission to publish my information.

4. I am the:

I am the: Parent

Guardian

Other (please specify)

5. Please list your children's names and their grade and school as of September 2012:

Please list your children's names and their grade and school as of September 2012: First Child
Second Child
Third Child
Fourth Child
Fifth Child

6. May we include your children's names, grades, and school in our members-only directory? (Including your children's information will help other parents/guardian's identify and contact you.)

May we include your children's names, grades, and school in our members-only directory? (Including your children's information will help other parents/guardian's identify and contact you.) Yes

7. How would you prefer to receive communication from the SAFE HOMES Parent Network of Franklin County? (Mark all that apply)

How would you prefer to receive communication from the SAFE HOMES Parent Network of Franklin County? (Mark all that apply) Postal mail

E-mail (your email address must be entered above)

Automated phone calls (your phone number must be listed above)

On-line social network groups (Twitter, facebook, etc.)

8. If someone referred you, please let us know their name so we can thank them!

If someone referred you, please let us know their name so we can thank them!