Household and Caregiver

This information will be shared with our funders and will allow us to keep Learn & Play Tampa Bay FREE. We thank you so much for your support! All information will remain confidential. 

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* 1. What is the best number to reach you? (813XXXXXXX)

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* 2. What is your email?

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* 4. What is your street address?

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* 5. What is your zipcode

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* 6. Number of adults in household

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* 7. Number of children under 18 in household

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* 8. Dominant language spoken at home

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* 9. Please answer the following based on the children and adults attending class with you

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* 10. Please provide date of birth (MM/DD/YYYY)

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* 11. Gender

  Male Female
Adult 1
Adult 2
Child 1
Child 2
Child 3
Child 4

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* 12. Ethnicity: Hispanic/Latino

  Yes No
Adult 1
Adult 2
Child 1
Child 2
Child 3
Child 4

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* 13. Race

  White  African-American American Indian Asian Native Hawaiian or Pacific Islander 2 or More Refused
Adult 1
Adult 2
Child 1
Child 2
Child 3
Child 4

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* 14. Is the child free-lunch eligible?

  Yes No N/A
Child 1
Child 2
Child 3
Child 4

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* 15. Child's grade

  Not yet Pre-K K
Child 1
Child 2
Child 3
Child 4

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* 16. Caregiver's highest level of education

  Some / No High school HS Graduate/GED Technical Certificate Some college Associate's Degree Bachelor's Degree Advanced Degree
Adult 1
Adult 2

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* 19. What is your relationship to the child attending with you today?

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* 20. Did you know Learn & Play Tampa Bay is a program of the Glazer Children’s Museum?

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* 21. How did you discover the Learn & Play Tampa Bay program?

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