Coffee and Conversations Birth - Kindergarten

Join Coffee and Conversations on the second Tuesday of each month at 1pm and the fourth Tuesday of each month at 7pm if you have children ages birth to Kindergarten.

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* 1. Please provide your contact information.

Name (First and Last)

Email Address

Phone Number

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* 2. What county do you live in?

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* 3. What is your race?

Black or African American

White or Caucasian

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Multiple Races

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* 4. What is your ethnicity?

Hispanic or Latino

Non-Hispanic or Latino

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* 5. Please provide your child's date of birth.

Date of Birth

Date

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* 6. What is your child's race?

Black or African American

White or Caucasian

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Multiple Races

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* 7. What is your child's ethnicity?

Hispanic or Latino

Non-Hispanic or Latino

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* 8. What is your child's diagnosis? Please check all that apply.

Autism

ADD/ADHD

Deaf/Blind

Developmental Delay

Intellectual Disability

Deaf/Hearing Impairment

Emotional Disability

Learning Disability

Multiple Disabilities

Other Health Impairment

Orthopedic Impairment

Speech & Language

Traumatic Brain Injury

Vision Impairment/Blind

Suspected Disability

None

Other (please specify)

Coffee and Conversations *Birth - Kindergarten*

Question Title

* 1. Please provide your contact information.

Question Title

* 2. What county do you live in?

Question Title

* 3. What is your race?

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* 4. What is your ethnicity?

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* 5. Please provide your child's date of birth.

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* 6. What is your child's race?

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* 7. What is your child's ethnicity?

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* 8. What is your child's diagnosis? Please check all that apply.

Coffee and Conversations Birth - Kindergarten