Triple P Discussion Groups Registration - Summer of Resilience

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* 1. First and Last Name

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* 2. Phone Number

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* 3. Email Address

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* 4. ZIP Code

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* 5. What is your gender?

Male

Female

Gender non-binary or genderfluid

Prefer not to say

Other (please specify)

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* 6. How would you best describe yourself? Please check all that apply.

Asian or Asian American

Black or African American

Hispanic or Latinx

Indigenous American or Alaska Native

Native Hawaiian or other Pacific Islander

White

Prefer not to say

Other (please specify)

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* 7. What is your primary language spoken at home?

English

Spanish

Chinese

Vietnamese

Korean

French

Other (please specify)

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* 8. What is the date of the discussion group you plan to attend?

Date / Time

Date

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* 9. How many children age 0 to 5 currently live in your household?

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* 10. How many children age 6 to 9 currently live in your household?

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* 11. How many children age 10 to 12 currently live in your household?

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* 12. How many children age 13 and older currently live in your household?

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* 13. What is your relationship to the child(ren) in your household?

Parent

Grandparent

Foster parent

Other family member (aunt, uncle, etc)

Guardian

Childcare provider

Other (please specify)

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* 14. Would you like to be contacted about future Triple P sessions?

Yes, by phone.

Yes, by email.

Yes, by phone or email.

No.

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* 15. How did you hear about Triple P?

TV commercial

Texas Public Radio (TPR)

Radio ad

Streaming music service (Spotify, Pandora, etc)

Bus shelter ad

Billboard or outdoor poster

Print newspaper ad

Social Media (Facebook, Instagram, Twitter, etc)

Triple P website

Community Agency or Program

Other (please specify)