* 1. I currently participate in the Great Start Collaborative and/or Great Start Parent Coalition. (This can be by attending family events planned by the groups)

* 2. In which school district do you LIVE?

* 3. Do you identify yourself within a specific cultural, racial or ethnic background?

* 4. Please tell us the number of children you have in each age group. Please fill in all that apply.

* 5. Which best describes you as a parent? Please indicate all that apply.

* 6. My family has received or is receiving the following Early Childhood/Family services in Monroe County. Please check all that apply.

* 7. I found services for children ages 0-5 in Monroe County were...

* 8. Please select the TOP THREE ISSUES on which you feel our community should focus.

Childhood health including dental health
Substance abuse; prescription and illegal
Preparing my child for kindergarten
Educating community about new recommendations for babies like "Safe Sleep"
Family support; meeting basic needs
Parenting education through community playgroups or other means
Dealing with challenging childhood behaviors
Stress management
Access to health care including insurance, immunizations, and finding a family doctor
Special needs/disabilities
Assistance in finding quality/affordable childcare options
Affordable and consistent mental health services
Childhood nutrition and obesity prevention
Prevention of teenage pregnancy/support for teen parents
Smoking cessation and education for pregnant mothers
Child abuse and neglect
Opportunities for all families to engage in community events

* 9. Additional comments: