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* 1. Contact Information

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* 2. Gender

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* 3. Race (please select all that apply)

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* 4. Ethnicity (please select all that apply)

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* 5. Please check all that apply. I am a…

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* 6. Number of children currently living in household

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* 7. Age of children currently living in household

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* 8. How did you hear about the Family Action Network? (Please provide the name of the organization that referred or nominated you)

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* 9. I prefer to be contacted by (select all that apply)

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* 10. The best time of day to reach me is (select all that apply)

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* 11. I am able to attend the Family Action Network Launch on May 18, 2022 at the Ohio Statehouse in Columbus, Ohio (check one)

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* 12. I am able to attend the three (3), 90-minute Family Action Network virtual trainings between April and May (please check one)

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* 13. If other than English, what is your primary language?

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* 14. Do you have a need for an English language or ASL interpreter?

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* 15. I have reliable access to (select all that apply):

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* 16. When I think about my family, the first word that comes to mind is:

Thank you! (Don't forget to click submit below)

A member of the Groundwork Ohio team will be in touch to inform you if you are selected to participate in the Family Action Network.

If you have questions please email FamilyAction@GroundworkOhio.org
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