Positive Discipline for Families Program Registration Form Survey

Question Title

* ADULT Participant (18+)

First Name:

Last Name:

Question Title

* Sex:

Female

Male

Sex/Gender:

Question Title

* Date of Birth:

Month/Day/Year

Date

Question Title

* Our program will be providing you informational handouts during the class series. How would you prefer to receive them?

Please check your preference:

electronically by email

hard copy sent by mail

Question Title

* Address:

Address

City/Town

State/Province

ZIP/Postal Code

Question Title

* County:

King

Snohomish

Other (please specify)

Question Title

* Email Address:

Question Title

* Phone Number:

Question Title

* Homeless?

Yes

Question Title

* All information is confidential

What is your birth country?

Race/ Ethnicity:

Question Title

* Are you Spanish/Hispanic/Latino?

Yes

Question Title

* Are you an immigrant or refugee or new arrival to the U.S.?

Yes

Question Title

* Have you ever served on active duty in the U.S. military (inc. Natl. Guard/Reserves)?

Yes

Question Title

* Are you a spouse or partner of a US military person?

Yes

Question Title

* Language(s) spoken at home:

English

Spanish

Other (please specify)

Question Title

* Are you non-English speaking or of limited English ability?

Yes

Question Title

* Do you have a special need/disability?

Yes

Question Title

* Are you a parent, family member or caregiver of a child with a special need/disability?

Yes

Question Title

* Children:

Number of children (UNDER 18) living in your household:

Question Title

* Please check the age of each child in household:

	0-11 months	1	2	3	4	5	6	7	8	9	10	11	12	13	14	15+
Child 1:	Child 1: 0-11 months	Child 1: 1	Child 1: 2	Child 1: 3	Child 1: 4	Child 1: 5	Child 1: 6	Child 1: 7	Child 1: 8	Child 1: 9	Child 1: 10	Child 1: 11	Child 1: 12	Child 1: 13	Child 1: 14	Child 1: 15+
Child 2:	Child 2: 0-11 months	Child 2: 1	Child 2: 2	Child 2: 3	Child 2: 4	Child 2: 5	Child 2: 6	Child 2: 7	Child 2: 8	Child 2: 9	Child 2: 10	Child 2: 11	Child 2: 12	Child 2: 13	Child 2: 14	Child 2: 15+
Child 3:	Child 3: 0-11 months	Child 3: 1	Child 3: 2	Child 3: 3	Child 3: 4	Child 3: 5	Child 3: 6	Child 3: 7	Child 3: 8	Child 3: 9	Child 3: 10	Child 3: 11	Child 3: 12	Child 3: 13	Child 3: 14	Child 3: 15+
Child 4:	Child 4: 0-11 months	Child 4: 1	Child 4: 2	Child 4: 3	Child 4: 4	Child 4: 5	Child 4: 6	Child 4: 7	Child 4: 8	Child 4: 9	Child 4: 10	Child 4: 11	Child 4: 12	Child 4: 13	Child 4: 14	Child 4: 15+
Child 5:	Child 5: 0-11 months	Child 5: 1	Child 5: 2	Child 5: 3	Child 5: 4	Child 5: 5	Child 5: 6	Child 5: 7	Child 5: 8	Child 5: 9	Child 5: 10	Child 5: 11	Child 5: 12	Child 5: 13	Child 5: 14	Child 5: 15+
Child 6:	Child 6: 0-11 months	Child 6: 1	Child 6: 2	Child 6: 3	Child 6: 4	Child 6: 5	Child 6: 6	Child 6: 7	Child 6: 8	Child 6: 9	Child 6: 10	Child 6: 11	Child 6: 12	Child 6: 13	Child 6: 14	Child 6: 15+
Child 7:	Child 7: 0-11 months	Child 7: 1	Child 7: 2	Child 7: 3	Child 7: 4	Child 7: 5	Child 7: 6	Child 7: 7	Child 7: 8	Child 7: 9	Child 7: 10	Child 7: 11	Child 7: 12	Child 7: 13	Child 7: 14	Child 7: 15+
Child 8:	Child 8: 0-11 months	Child 8: 1	Child 8: 2	Child 8: 3	Child 8: 4	Child 8: 5	Child 8: 6	Child 8: 7	Child 8: 8	Child 8: 9	Child 8: 10	Child 8: 11	Child 8: 12	Child 8: 13	Child 8: 14	Child 8: 15+

Question Title

* ADULT Participant (18+)

Question Title

* Sex:

Question Title

* Date of Birth:

Question Title

* Our program will be providing you informational handouts during the class series. How would you prefer to receive them?Please check your preference:

Question Title

* Address:

Question Title

* County:

Question Title

* Email Address:

Question Title

* Phone Number:

Question Title

* Homeless?

Question Title

* All information is confidential

Question Title

* Are you Spanish/Hispanic/Latino?

Question Title

* Are you an immigrant or refugee or new arrival to the U.S.?

Question Title

* Have you ever served on active duty in the U.S. military (inc. Natl. Guard/Reserves)?

Question Title

* Are you a spouse or partner of a US military person?

Question Title

* Language(s) spoken at home:

Question Title

* Are you non-English speaking or of limited English ability?

Question Title

* Do you have a special need/disability?

Question Title

* Are you a parent, family member or caregiver of a child with a special need/disability?

Question Title

* Children:

Question Title

* Please check the age of each child in household:

Question Title

* TOTAL number of ALL people living in your household:

* Our program will be providing you informational handouts during the class series. How would you prefer to receive them?

Please check your preference: