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Strengthening Families Program for Parents & Youth 10-14
Level of Interest Survey
*
1.
Which school district do you reside in?
(Required.)
Pottsville Area School District
Minersville Area School District
Schuylkill Haven Area School District
St. Clair School District
*
2.
Name of Student
(Required.)
*
3.
Age of Student
(Required.)
10
11
12
13
14
*
4.
Grade Level
(Required.)
5th
6th
7th
8th
Other
*
5.
Name of Parent / Guardian / Caregiver:
(Required.)
*
6.
Contact Phone Number:
(Required.)
*
7.
Contact Email Address:
(Required.)
*
8.
Are we permitted to send you SFP 10-14 updates via TEXT?
(Required.)
Yes
No
*
9.
Are we permitted to send you SFP 10-14 updates via EMAIL?
(Required.)
Yes
No
10.
If you have additional children in this age range, please list their name and age here.
*
11.
Please choose one of the following:
(Required.)
I would like to register for SFP 10-14
I would like to learn more about SFP 10-14
I may be interested in registering for SFP 10-14 at a later time
I've already completed SFP 10-14
I am not interested in SFP 10-14
Current Progress,
0 of 11 answered
