Derek Clark — Never Limit Life — Never Give Up! Survey

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* 1. Please Select all trainings that you wish to attend:

Wednesday, May 17, 2023 — Derek Clark presents Never Limit Life — Never Give Up!
5:45 - 7:45pm at Yreka Church of the Nazarene, 415 Evergreen Lane, Yreka

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* 2. Participants Information

First and Last Name

City/ Town

State

ZIP/Postal Code

Phone Number

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* 3. Email

Please enter your email

Please confirm your email

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* 4. For planning for dinner, how many in your family will be attending this event?

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* 5. Do you need child care for this event?

Yes

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* 6. If yes (regarding child care), please list number of children and ages, and training date (April 15th and/or May 13th).

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* 7. Would you like to receive, by e-mail, information about future trainings, activities, and events relating to parenting and professional development in Siskiyou county?

Yes

Already on the list

No, thank you

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* 8. Please Check All That Describe You:

Adoptive parent with child under age 18

In the process of adoption of children under age 18

Birth Parent with children under age 18

Foster Parent

Informal Relative/ Kinship Care Provider/ Non-Related Extended Family Member (ie. grandparents raising grandchildren)

Provider of child care as needed for family, friend, or neighbor

State-funded preschool provider

Early Head Start/Head Start Center Based

Early Head Start or Other Home Visitation Programs

Community Member interested in the topic

Social Services Professional

County Probation Staff

Foster Family Agency Staff

Short Term Residential Therapeutic Program Staff (Previously Group Home)

Family Resource Center Staff/Volunteer/Board Member

Health Care Professional/ Administration

Teacher/Staff - Preschool

K-12+ administrator, teacher, staff

College Faculty/Administration/Staff

Law Enforcement

Tribal Program Staff

Student

County Board of Supervisor/City Council/Special District Member

County/City Administration

Community-based Non-profit

CASA Volunteer

Behavioral/Mental Health

Family or community advisory board

Community or Family Resource Center Board member, staff, or volunteer

Other Non-Profit

Other (please specify)

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* 9. Are you interested in being a Resource Family? (Foster Parent)

Yes

Possibly, would like more information

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* 10. Would you like a Certificate emailed to you to show your completion of participation in this training?

Yes