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Family Involvement Committee Interest Form
KCICC Family Involvement Committee Interest Form
1.
Name (First and Last) Mailing Address, Email, Phone Number
Name
Address
Address 2
City/Town
State/Province
ZIP/Postal Code
Email Address
Phone Number
2.
How do you identify?
American Indian or Alaskan Native
Asian
Native Hawaiian or other Pacific Islander
Black or African American
Hispanic or Latin (X)
White
Prefer not to respond
Self-Identify
3.
Do you need an interpreter?
Yes
No
4.
If you need an interpreter, what is the language?
5.
Did your child(ren) ever receive Early Support for Infants and Toddlers, also known as Birth to Three services?
Yes
No
6.
Can you commit to 5 in-person meetings?
Yes
No
7.
Why are you interested in becoming a Family Involvement Committee member?
Current Progress,
0 of 7 answered