3Ts Let's Talk Program Application

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* 1. What is your name?

First

Last

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* 2. What is the best phone number reach you?

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* 3. What is your email address?

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* 4. Are you an Arizona resident?

Yes

No

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* 5. Have you or your co-parent ever participated in the Let's Talk Dads program?

Yes

No

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* 6. What is your co-parent's/partner's name? (If applicable)

First

Last

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* 7. What is your co-parent's/partner's email address? (If applicable)

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* 8. Do you have a child under the age of 4 years old?

Yes

No

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* 9. What is their first name?

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* 10. What is their date of birth?

Date

Date

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* 11. Preferred shipping address for Let's Talk materials?

Mailing Address

City

State

Zip Code

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* 12. What language do you prefer your children's books to be provided in?

English

Spanish

Bilingual English/Spanish

Other (please specify)

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* 13. Do you have access to a desktop or laptop computer at home? (Not including a smart phone or tablet)

Yes

No