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0-5 Active Parenting Class Registration 2026-2027
*
1.
What is your name?
(Required.)
*
2.
Contact information
(Required.)
Name
Address
Address 2
City/Town
State/Province
ZIP/Postal Code
Email Address
Phone Number
*
3.
Number in household
(Required.)
*
4.
Which of the following best describes your current relationship status?
(Required.)
Married
Widowed
Divorced
Separated
In a domestic partnership or civil union
Single, but cohabiting with a significant other
Single, never married
5.
How many children, by age, currently live in your household?
Less than 1 year old
1 year old
2 years old
3 years old
4 years old
5 years old
6 years old
7 years old
8 years old
9 years old
10 years old
11 years old
12 years old
13 years old
14 years old
15 years old
16 years old
17 years old
18 years old or older
6.
Referral Source - if referred
7.
Which race/ethnicity best describes you? (Please choose only one.)
American Indian or Alaskan Native
Asian / Pacific Islander
Black or African American
Hispanic
White / Caucasian
Multiple ethnicity / Other (please specify)
8.
Do you receive TANF?
Yes
No
9.
Are children enrolled in Head Start/Early Head Start?
Yes
No
10.
Are you a former Head Start parent?
Yes
No
*
11.
Last four of social (for identification purposes only)
(Required.)
12.
Date of birth
Date
Date
January
February
March
April
May
June
July
August
September
October
November
December
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
Su
Sunday
Mo
Monday
Tu
Tuesday
We
Wednesday
Th
Thursday
Fr
Friday
Sa
Saturday
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
13.
Are you currently employed?
Yes
No
*
14.
What is your household income?
(Required.)
Under $15,000
Between $15,000 and $29,999
Between $30,000 and $49,999
Between $50,000 and $74,999
Between $75,000 and $99,999
Between $100,000 and $150,000
Over $150,000
15.
What is the highest level of school you have completed or the highest degree you have received?
Less than high school degree
High school degree or equivalent (e.g., GED)
Some college but no degree
Associate degree
Bachelor degree
Graduate degree
16.
What do you hope to learn from this class?
Current Progress,
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