Healthy Parenting - Registration Form

All activities are FREE. This is a 3-week program.

*Required

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* 1. Contact information

Name

Email Address

Phone Number

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* 2. Do you have a child ages 2 to 7 years old?

Yes

No

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* 3. This is a 3-week program. Will you be able to attend at least 2 out of the 3 classes?

Yes

No

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* 4. What is your age?

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* 5. What is your race/ethnicity?
(Check all that apply)

Asian

Hispanic, Latino or Spanish

Native Hawaiian or Other Pacific Islander

American Indian or Alaska Native

Black or African American

White

Prefer not to say

Other (please specify)