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.

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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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* 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

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

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* 13. Ethnicity: Hispanic/Latino

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

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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 2
Child 1
Child 2
Child 3
Child 4

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* 15. Child's grade

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

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* 16. Is the child free-lunch eligible?

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

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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

  Some or no high school High school graduate or GED Technical Certificate Some college Associates Degree Bachelor's Degree Advanced Degree
Adult 1
Adult 2

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* 19. Military (Active duty or retired)

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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. 

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

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