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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* 3. What is your street address?

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* 4. City

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* 5. What is your zipcode

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* 6. Number of adults in household

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* 7. Number of children under 18 in household

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* 8. Dominant language spoken at home

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* 9. Please answer the following based on the adults attending class

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* 10. Please provide the adults date of birth (MM/DD/YYYY)

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* 11. Please answer the following based on the children under 5 years old attending class with you

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* 12. Please provide children's date of birth (MM/DD/YYYY)

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* 13. Gender

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

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* 14. 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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* 15. 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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* 16. Child's grade

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

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* 17. Is the child free-lunch eligible?

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

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* 18. Areas of concern you would like our staff to assist with (Check all that apply)

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

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* 23. Check all that apply

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* 24. Have you attended any similar early learning programs like Learn & Play?

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* 25. Do you have Glazer Children's Museum Membership?

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

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

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