Nurture KC- Group Education Registration

The following demographic questions are required by the Healthy Start grant. No information that can identify you will be shared. You can decline to answer any of the questions below.

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* 1. Your Name

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* 2. Your date of birth

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* 3. Are you currently...?

Preconceptive (no prior pregnancies, no prior children, not pregnant)

Pregnant or expecting

Postpartum (delivered less than 6 months prior to today)

Parenting an infant less than 6 months of age

Parenting a child 12- 18 months of age

None of the above

Declined to answer

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* 4. What is your age in years?

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* 5. What is your sex?

Female

Male

Declined to answer

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* 6. Are you of Hispanic, Latino/a, or Spanish origin?

No, not of Hispanic, Latino/a, or Spanish origin

Yes, Mexican, Mexican American, Chicano/a

Yes, Puerto Rican

Yes, Cuban

Yes, Another Hispanic, Latino/a, or Spanish origin

Declined to answer

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* 7. What is your race?

White

Black or African American

American Indian or Alaska Native

Asian Indian

Filipino

Japanese

Korean

Vietnamese

Other Asian

Native Hawaiian

Guamanian or Chamorro

Samoan

Other Pacific Islander

Declined to answer

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* 8. Do you speak a language other than English at home?

Declined to answer

Yes (please specify language)

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* 9. How well do you speak English?

Very well

Well

Not well

Not at all

Declined to answer

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* 10. What is the highest grade or level of school that you have completed?

No formal schooling

8th grade or less

Some high school (Grades 9, 10, 11 & 12)

High school diploma (completed 12th grade)

G.E.D.

Some college or 2-year degree

Technical or trade school

Graduate or professional school

Declined to answer

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* 11. Are you currently enrolled as a Kansas City Healthy Start Participant at Nurture KC?

Yes

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* 12. What group education or you registering to attend? (Previously recorded) Mark all that apply.

Family Financial Literacy

Nutrition for Well-Being

Soft Parenting During Hard Times

Fathers and Maternal Mental Health

Understanding Birth 101

Nurture KC- Group Education Registration

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* 1. Your Name

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* 2. Your date of birth

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* 3. Are you currently...?

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* 4. What is your age in years?

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* 5. What is your sex?

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* 6. Are you of Hispanic, Latino/a, or Spanish origin?

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* 7. What is your race?

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* 8. Do you speak a language other than English at home?

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* 9. How well do you speak English?

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* 10. What is the highest grade or level of school that you have completed?

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* 11. Are you currently enrolled as a Kansas City Healthy Start Participant at Nurture KC?

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* 12. What group education or you registering to attend? (Previously recorded) Mark all that apply.

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* 13. What is your email address? (This is to verify your attendance, deliver meeting links, and send any applicable gift cards.)