2022 REGISTRATION FOR LEARN & PLAY Survey

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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

	Hispanic or Latino	Not Hispanic or Latino	NA
Adult 1	Adult 1 Hispanic or Latino	Adult 1 Not Hispanic or Latino	Adult 1 NA
Adult 2	Adult 2 Hispanic or Latino	Adult 2 Not Hispanic or Latino	Adult 2 NA
Child 1	Child 1 Hispanic or Latino	Child 1 Not Hispanic or Latino	Child 1 NA
Child 2	Child 2 Hispanic or Latino	Child 2 Not Hispanic or Latino	Child 2 NA
Child 3	Child 3 Hispanic or Latino	Child 3 Not Hispanic or Latino	Child 3 NA
Child 4	Child 4 Hispanic or Latino	Child 4 Not Hispanic or Latino	Child 4 NA

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* 14. Race

	White	Black or African-American	American Indian or Alaska Native	Asian	Native Hawaiian or Other Pacific Islander	Two or More Races	Refused
Adult 1	Adult 1 White	Adult 1 Black or African-American	Adult 1 American Indian or Alaska Native	Adult 1 Asian	Adult 1 Native Hawaiian or Other Pacific Islander	Adult 1 Two or More Races	Adult 1 Refused
Adult 2	Adult 2 White	Adult 2 Black or African-American	Adult 2 American Indian or Alaska Native	Adult 2 Asian	Adult 2 Native Hawaiian or Other Pacific Islander	Adult 2 Two or More Races	Adult 2 Refused
Child 1	Child 1 White	Child 1 Black or African-American	Child 1 American Indian or Alaska Native	Child 1 Asian	Child 1 Native Hawaiian or Other Pacific Islander	Child 1 Two or More Races	Child 1 Refused
Child 2	Child 2 White	Child 2 Black or African-American	Child 2 American Indian or Alaska Native	Child 2 Asian	Child 2 Native Hawaiian or Other Pacific Islander	Child 2 Two or More Races	Child 2 Refused
Child 3	Child 3 White	Child 3 Black or African-American	Child 3 American Indian or Alaska Native	Child 3 Asian	Child 3 Native Hawaiian or Other Pacific Islander	Child 3 Two or More Races	Child 3 Refused
Child 4	Child 4 White	Child 4 Black or African-American	Child 4 American Indian or Alaska Native	Child 4 Asian	Child 4 Native Hawaiian or Other Pacific Islander	Child 4 Two or More Races	Child 4 Refused

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* 15. Child's grade

	Not yet in school	Pre-Kindergarten	Kindergarten
Child 1	Child 1 Not yet in school	Child 1 Pre-Kindergarten	Child 1 Kindergarten
Child 2	Child 2 Not yet in school	Child 2 Pre-Kindergarten	Child 2 Kindergarten
Child 3	Child 3 Not yet in school	Child 3 Pre-Kindergarten	Child 3 Kindergarten
Child 4	Child 4 Not yet in school	Child 4 Pre-Kindergarten	Child 4 Kindergarten

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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 or no high school	High school graduate or GED	Technical Certificate	Some college	Associates Degree	Bachelor's Degree	Advanced Degree
Adult 1	Adult 1 Some or no high school	Adult 1 High school graduate or GED	Adult 1 Technical Certificate	Adult 1 Some college	Adult 1 Associates Degree	Adult 1 Bachelor's Degree	Adult 1 Advanced Degree
Adult 2	Adult 2 Some or no high school	Adult 2 High school graduate or GED	Adult 2 Technical Certificate	Adult 2 Some college	Adult 2 Associates 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. If you are experiencing any situation that might limit your participation for in-person sessions, you may qualify for Learn & Play @ Home sessions & content!

Please note, Learn & Play does not ask for any further information regarding your answer to this question.

No Reliable Transportation

Health-Related Concern

Disability

Not Applicable

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

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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

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

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

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* 12. Gender

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* 13. Ethnicity: Hispanic/Latino

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* 14. Race

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* 15. Child's grade

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* 16. Is the child free-lunch eligible?

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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

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* 18. Caregiver's highest level of education

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* 19. Military (Active duty or retired)

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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?

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

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

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* 25. If you are experiencing any situation that might limit your participation for in-person sessions, you may qualify for Learn & Play @ Home sessions & content! Please note, Learn & Play does not ask for any further information regarding your answer to this question.

* 25. If you are experiencing any situation that might limit your participation for in-person sessions, you may qualify for Learn & Play @ Home sessions & content!

Please note, Learn & Play does not ask for any further information regarding your answer to this question.