* 1. Family Information

* 2. How many children (ages 0-5) LIVE in your home?

* 3. Please give the ages of the kids who LIVE with you?

  Under 12 months 1-2 years old 3-4 years old 5-7 years old 8-12 years old 12+ years old
Child #1
Child #2
Child #3
Child #4
Child #5
Child #6

* 4. Do you provide childcare for any additional children in your home?

* 5. If yes, how many additional children (ages 0-5) do you provide childcare for? (DO NOT include children living with you)

* 6. Please tell us how you heard about the Safety Day?

* 7. Primary language spoken in the home

* 8. Two volunteers will be coming to your home between the hours of 9am-12pm on Saturday, October 5th.

Will you be the adult home during the Safety Day visit?

* 9. In no, who will be the adult in the home during the visit?

* 10. A member of the "Building Safety on Your Block" team will be in contact the week of October 5th to verify you'll still be able to participate and answer any questions you may have. Do you prefer to be contacted for confirmation via: