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Immunize Kansas Coalition | Parent Group Interest Survey
IKC Parents & Families Interest Survey
Please complete this form to let us know of your interest in learning more about and/or joining the IKC Parents & Families group.
*
1.
Name
(Required.)
2.
Mailing Address
Address
Address 2
City/Town
State/Province
ZIP/Postal Code
*
3.
Email Address
(Required.)
4.
Phone Number
5.
This number is...
Home
Work
Cell
*
6.
How did you hear about the IKC Parents group?
(Required.)
Health provider
Social media
Family, friend, or co/worker
Other (please specify)
*
7.
Primarily, we would like to connect parents and develop community through a closed IKC Parents Facebook group, moderated by IKC Board members and staff. Do you currently have a Facebook account?
(Required.)
Yes
No
Yes, but I would not like to be part of the IKC Parents Facebook group.
No, but I would consider getting one to be part of the IKC Parents Facebook group.
I would like to connect but prefer not to use social media.
8.
Do any of these other activities interest you?
Participating in a webinar, podcast, or online Q&A session for parents, featuring expert panelists from the IKC Board
Attending a portion of an IKC meeting (in-person or phone) for a parent-specific discussion
Subscribe to and engage in conversations on an email list-serv
Participate in advocacy and education events in support of immunizations
Other (we're open to your ideas!)
9.
What would you want or expect to get out of participating in the IKC Parents group?
