Pop-Up Care Required Information Form

About You

The information on this form helps up provide the best service for you and your children. In most cases, this information is required for our program's funding. Thank you for taking the time to complete this form. If you have any questions, please contact us at childcare@risecdc.org.

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* 1. First name

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* 2. Last name

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* 3. What is your phone number?

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* 4. What is your email?

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* 5. How do you prefer to be contacted?

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* 6. How did you hear about us?

Facebook

Instagram

Other social media

RISE newsletter

Other newsletter

Flyer

Friend or other word-of-mouth

Black Mamas Village

At an event outside of TVP/BMV

Other (please specify)

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* 7. What is your age group?

Under 18

18 To 24

25 To 39

40 To 54

55 To 64

65 To 74

75 And Older

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* 8. What is your home zip code (put N/A if you are experiencing homelessness)

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* 9. What is your average yearly household income?

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* 10. How many people currently live in your household (including you)?

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* 11. What is your race/ethnicity?

American Indian or Alaska Native

Asian or Asian American

Black or African American

Hispanic or Latino or Latine

Native Hawaiian or Other Pacific Islander

White

Multi-racial

Prefer not to respond

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* 12. What is your gender/gender identity?

Woman

Non-binary

Man

Prefer not to answer

Not listed

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* 13. Do you live with a disability (physical, mental, emotional, etc.)?

Yes

Prefer not to answer