2025 Participant Registration Form

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* 1. Name (First and Last)

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* 2. Your Date or Birth:

Date of Birth

Date

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* 3. Gender

Male

Female

Prefer not to answer

Other (please specify)

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* 4. What is your street address? (Include city and zip code)

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* 5. Phone Number

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* 6. At what email address would you like to be contacted?

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* 7. Combined Household Income Annually:

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* 8. Primary Language you speak:

English

Spanish

Hmong

Other (please specify)

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* 9. Race:

White or Caucasian

Black or African American

Hispanic or Latino

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Another race

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* 10. Ethnicity:

Hispanic or Latino

Not Hispanic or Latino

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* 11. Are you:

Not Disabled

Disabled

Disabled receiving SSI

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* 12. Marital Status:

Married

Remarried

Separated

Widowed

Divorced

Single and never married

Living with my partner

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* 13. Your Religion:

Amish

Catholic

Jewish

Mennonite

Muslim

Protestant

Non-Denominational

No Religious Affiliation

Other (please specify)

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* 14. My family is currently dealing with (check all that apply):
Please Note: We use this information to help us understand the needs of the families we serve. If you would like assistance with these or any other issues, please talk to a staff member.

Divorce/Separation

Alcohol/drug use

job loss/unemployment

child custody dispute

mental health issues

death in the family

struggling to make ends meet

relocation/moving

homelessness

raising a child with special needs

teen pregnancy/parenting

Child Protective Services involvement

incarceration/probation/parole

Other (please specify)

None of the above

2025 Participant Registration Form

Question Title

* 1. Name (First and Last)

Question Title

* 2. Your Date or Birth:

Question Title

* 3. Gender

Question Title

* 4. What is your street address? (Include city and zip code)

Question Title

* 5. Phone Number

Question Title

* 6. At what email address would you like to be contacted?

Question Title

* 7. Combined Household Income Annually:

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* 8. Primary Language you speak:

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* 9. Race:

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* 10. Ethnicity:

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* 11. Are you:

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* 12. Marital Status:

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* 13. Your Religion:

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* 14. My family is currently dealing with (check all that apply):Please Note: We use this information to help us understand the needs of the families we serve. If you would like assistance with these or any other issues, please talk to a staff member.

* 14. My family is currently dealing with (check all that apply):
Please Note: We use this information to help us understand the needs of the families we serve. If you would like assistance with these or any other issues, please talk to a staff member.