2022 REGISTRATION FOR LEARN & PLAY Survey

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

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* 2. What is your email?

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* 3. Which Learn & Play site are you seeking to attend

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* 4. What is your street address?

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* 5. City

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* 6. What is your zipcode

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* 7. Number of adults in household

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* 8. Number of children under 18 in household

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* 9. Dominant language spoken at home

English

Spanish

Other (please specify)

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

Adult 1: Full name

Adult 2: Full Name

Child 1 Full Name

Child 2 Full Name

Child 3 Full Name

Child 4 Full Name

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

Adult 1

Adult 2

Child 1

Child 2

Child 3

Child 4

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* 12. Gender

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

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* 13. Ethnicity: Hispanic/Latino

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

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* 14. Race

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

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* 15. Child's grade

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

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* 16. Is the child free-lunch eligible?

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

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

Speech

Behavioral

Physical

Separation Anxiety

Special Needs

IEP

Not Applicable

Other (please specify)

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

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* 19. Military (Active duty or retired)

Yes

Not Applicable

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* 20. Household income

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* 21. Head of Household (According to IRS)

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

Parent

Relative

Friend or Neighbor

Childcare Provider

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

Yes

If yes- specify

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

Other Museum Program

GCM Newsletter or Print Ad

GlazerMuseum.org

Social Media

Children's Board of Hillsborough County

A Relative, Friend or Neighbor

Other (please specify)

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* 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!

No Reliable Transportation

Health-Related Concern

Disability

Not Applicable

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