Full Name
*
Date of Birth
*
-
Month
-
Day
Year
Date
Email
example@example.com
Address/City/State and zip code
*
Phone number
*
Have you been previously incarcerated?
Yes
No
HAVE YOU EVER BEEN CONVICTED OF A VIOLENT OR SEXUAL OFFENSE?
*
Yes
No
Maybe
DATE OF OFFENSE
-
Month
-
Day
Year
Date
ARE THERE ANY PENDING CHARGES? IF SO WHAT JURISDICTION?
ARE YOU ON PROBATION/PAROLE?
*
WHAT’S YOUR PAROLE OFFICER NAME?
*
WHAT’S THE PAROLE OFFICER PHONE NUMBER/CONTACT INFORMATION?
*
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Children & Education
DO YOU HAVE KIDS?
*
Yes
No
HOW MANY CHILDREN DO YOU HAVE?
*
WHAT IS THE AGE OF YOUR CHILD(s)?
WILL THEY BE LIVING WITH YOU?
*
Yes
No
Maybe
IF YOUR KIDS ARE NOT LIVING WITH YOU, HOW OFTEN DO YOU SEE THEM?
WHO IS YOUR CHILD(s) PRIMARY CARETAKER?
*
WHAT IS THE AGE OF THE CARETAKER?
*
DO YOUR CHILDREN ATTEND SCHOOL?
*
Yes (online included)
No
Maybe
HOW IS YOUR CHILD'S SCHOOL AFFECTED BY COVID-19?
Online schooling
No school
Part-time in-person
IF YOUR CHILDREN ARE DOING ONLINE SCHOOLING, WHO IS FACILITATING THEIR LEARNING AT HOME?
DOES YOUR CHILD(s) HAVE AN IEP (Individualized Education Program is a written document that's developed for each public school child who is eligible for special education)? IF SO, WHAT IS IT?
*
Yes
No
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Parenting & Family Time
HOW MANY HOURS A WEEK DO YOU SPEND WITH YOUR CHILD(s)?
*
HOW MANY HOURS A WEEK DO YOU SPEND DOING ACTIVITIES WITH YOUR CHILD(s) (i.e. reading, talking, watching something, playing a game, etc.)?
*
0-3 hours a week
4-6 hours a week
6-8 hours a week
8 or more hours a week
WHAT KIND OF ACTIVITIES ARE YOU INTERESTED IN LEARNING MORE ABOUT?
*
Games with your child(s)
Co-viewing educational shows
Crafts
Conversations starters
Skill building
Outdoor activities
Exercise
WHAT IS A PARENTING STRENGTH OF YOURS?
*
WHAT IS A PARENTING WEAKNESS OF YOURS?
*
WHAT IS YOUR COMMUNICATION STYLE?
*
WHAT IS A COMMON FAMILY ACTIVITY IN YOUR HOUSEHOLD?
*
WHAT ARE YOUR GOALS FOR THIS WORKSHOP?
*
IN WHAT WAYS YOU THINK YOUR RELATIONSHIP WITH YOUR CHILD(s) COULD IMPROVE?
*
WHAT ARE SOME THINGS YOU WISH YOU COULD TALK TO YOUR CHILD(s) ABOUT?
*
DO YOU DISCUSS YOUR INCARCERATION WITH YOU CHILD(s)
*
Yes
No
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Needs
WHAT TECHNOLOGY DO YOU HAVE ACCESS TO AT HOME? Select all that apply.
*
Smartphone
Tablet
Computer/Laptop
TV
Wi-Fi
DO YOU NEED HOUSING?
*
Yes
No
Maybe
DO YOU NEED HEALTHCARE?
*
Yes
No
Maybe
DO YOU NEED A PARENTING CLASS?
*
Yes
No
Maybe
DO YOU NEED SUBSTANCE ABUSE COUNSELING?
*
Yes
No
Maybe
HOW CAN WE HELP YOU?
*
EMERGENCY CONTACT NAME?
*
EMERGENCY CONTACT PHONE NUMBER?
*
HOW DID YOU HEAR ABOUT BUILD-A-DAD/MOM WORKSHOP?
*
Personal information collected on this form is for the purpose of enrollment in the Build-A-DAD/MOM Workshop program, A Better Day Than Yesterday Initiative. Personal information gathered will be managed in accordance with the Freedom of Information and Protection of Privacy Act.
*
Yes I agree
No I don’t agree
Submit
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