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Cultivating Fathers
Program Application
Participant Contact Information
Name
*
First Name
Middle Initial
Last Name
Suffix
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone
*
Email Address
*
example@example.com
Demographics
Date of Birth
*
/
Month
/
Day
Year
Gender
*
Male
Female
Prefer Not to Answer
Other
Ethnicity
*
Please Select
Hispanic
Not Hispanic
Race
*
Please Select
African American
Asian
Bi-Racial
Caucasian
Hawaiian or Pacific Islander
Hispanic
Multi-Racial
Native American
Other
Other Phone
Please enter a valid phone number.
Family Information
What is your marital status?
*
Please Select
Single
Married
Separated
Widowed
Common Law
Divorced
Domestic Partner
How many total children do you have?
*
Please Select
1
2
3
4
5
6
7
8
9
10
How many children under the age of 18?
*
Please Select
1
2
3
4
5
6
7
8
9
10
Education Information
What is the highest level of education you have completed?
*
Please Select
9th grade
10th grade
11th grade
12th grade
HS Diploma
GED
Some college
Technical Degree
Associate's
Bachelor's
Other
Employment Information
What is your current employment status?
*
Please Select
Unemployed
Full-Time
Part-Time
Self-Employed (Full-Time)
Self-Employed )Part-Time_
Informal Employment (Cash Jobs)
Disabled
Retired
More Information
Is there anything that will prevent you from completing the program? Transportation, childcare, work schedule etc. (Program days are Tuesdays and Thursdays 6:30-8:30pm)
*
Yes
No
If yes, please explain:
Briefly tell us why you are interested in the Cultivating Fathers Program:
*
How did you hear about this program?
*
Please Select
Friend or family
PO
Child Support Court
Case Worker
Self-Referral
Social Media
Website
IPO
Other
Agency Referral: (Please provide Agency, Name, Phone number and Email)
What cohort are you able to attend?(Fall, Spring or Summer)
Today's Date
*
-
Month
-
Day
Year
Submit
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