Please include all adults and children under 5 who will attend sessions

All information will remain confidential. 
Once completed, you will be registered for our program and can participate in any of our sessions. Also, be sure to check your email for weekly Learn & Play news and updates.

Question Title

* 1. What is the best number to reach you? (813XXXXXXX)

Question Title

* 2. What is your email?

Question Title

* 4. What is your street address?

Question Title

* 5. City

Question Title

* 6. What is your zipcode

Question Title

* 7. Number of adults in household

Question Title

* 8. Number of children under 18 in household

Question Title

* 9. Dominant language spoken at home

Question Title

* 10. Please answer the following based on the children and adults attending class with you

Question Title

* 11. Please provide date of birth (MM/DD/YYYY)

Question Title

* 12. Gender

  Male Female
Adult 1
Adult 2
Child 1
Child 2
Child 3
Child 4

Question Title

* 13. Ethnicity: Hispanic/Latino

  Yes No NA
Adult 1
Adult 2
Child 1
Child 2
Child 3
Child 4

Question Title

* 14. Race

  White  African-American American Indian Asian Native Hawaiian or Pacific Islander 2 or More Refused
Adult 1
Adult 2
Child 1
Child 2
Child 3
Child 4

Question Title

* 15. Child's grade

  Not yet Pre-K K
Child 1
Child 2
Child 3
Child 4

Question Title

* 16. Is the child free-lunch eligible?

  Yes No N/A
Child 1
Child 2
Child 3
Child 4

Question Title

* 17. Are any of your children currently receiving services or would you like information on any of the following? Check all that apply

Question Title

* 18. Caregiver's highest level of education

  Some / No High school HS Graduate/GED Technical Certificate Some college Associate's Degree Bachelor's Degree Advanced Degree
Adult 1
Adult 2

Question Title

* 19. Military (Active duty or retired)

Question Title

* 22. What is your relationship to the child attending with you today?

Question Title

* 23. Have you attended any similar early learning programs before Learn & Play

Question Title

* 24. How did you discover the Learn & Play Tampa Bay program?

Question Title

* 25. List any challenges that might limit your participation in community in-person sessions. You may qualify for our exclusive Virtual Learn & Play @ Home sessions & content!

Follow our Social Media @LearnPlayTampaBay for updates on new locations, schedules, and more!

T