Dual Gen: Effective Black Parenting Program Referral Form
As a United Way Dual Gen partner, EHSA offers an Effective Black Parenting (EBP) series of parenting classes that are evidence-based and culturally relevant in raising proud, confident and healthy black children. This 8-week program is open to all parents and includes topics such as: The Social Learning Theory, The Effective Praise Method, Traditional and Modern Disciplining, Children’s Developing Abilities, Family Rules, and more. Online options are available to join a cohort of parents, creating supportive, safe spaces for learning. Qualifying parents enrolled in EBP have the opportunity to receive additional services such as child care, trade/college tuition and financial assistance. Eligibility: Open to all community members with children 0-10 years of age in the following zip codes: 78202, 78203,78205, 78207, 78208, 78210, 78211, 78215,78218, 78219, 78220, 78221, 78225 78222,78227,78237. (slots available for families in adjacent zip codes)
Community Member Information:
* = required information
Title
*
Please Select
Ms.
Mrs.
Mr.
Mx.
Dr.
Please use my first name
Name
*
First Name/1er Nombre
Last Name/Apellido
Available Group Classes (ONLINE) Waitlist
*
11:45 AM - 1:00 PM: Every Tuesday & Thursday
6:00 PM - 7:15 PM: Every Tuesday & Thursday
I'd like to alternate between day and evening classes depending on my schedule
Available Group Classes (In-Person) Waitlist
*
11:45am - 1:00pm: Every Monday & Wednesday
6:00pm - 7:15pm: Every Monday & Wednesday
I'd like to alternate between day and evening classes depending on my schedule.
Additional Availability Comments
What Dual Gen services are you interested in? (select all that apply)
*
Effective Black Parenting Classes (EBP)
Obtaining job training
Obtaining higher education (GED included)
E-mail
*
example@example.com
Phone Number
*
Preferred Method of Contact
*
Please Select
Phone call
Text Message
Email
Address
*
Street Address/Dirección o número de calle y apartamento si aplica
City/Ciudad
State / Province-Estado/Provincia
Zipcode/Código postal
How did you hear about Empower House?
*
Please Select
Avance
Family Service Association
KLRN
Madonna Center
Project Quest
Restore Education
CPS (Child Protective Services)
Case Manager, Social Worker, Therapist
Other Referral
Community Member
Instagram
Facebook
Community Event
Empower House Staff
Empower House Radio 101.5
Internet Search
If you selected Other Referral: Who referred you?
Please complete the following documents as a prerequisite for participation in the Dual Generation Program.
*
Protective Factors Survey: https://form.jotform.com/242485354844060
Cantril's Ladder: https://form.jotform.com/231374950458058
Guardian and Child Information
Guardian Gender
*
Please Select
woman/girl
man/boy
genderfluid
non-binary
transgender woman
transgender man
prefer not to answer
none of the above
Guardian Ethnicity
*
Please Select
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
Hispanic/Latinx
More than one of the above
None of the above
Decline to answer
Number of children
*
Ages of Children
*
Are you currently enrolled in school
*
Please Select
Yes
No
Would you be interested in exploring any of the other programs offered through Empower House?
Empower Choice
Empower Connects (Digital Literacy)
Community Health Worker
Mental Health Programing
Healing Circles
Monthly email newsletter? / ¿Desea ser añadido a nuestro boletín informativo mensual por correo electrónico?
Yes/Sí
No, thank you/No gracias
Email updates from Empower House about our essential programing and services? Quiere que le mandemos correos electrónicos sobre nuestros programas y servicios esenciales?
Yes Sí
No, thank you/ No gracias
Text updates from Empower House about our essential programming and services? Quiere recibir textos sobre nuestros programas y servicios esenciales?
Yes/Sí
No, thank you/No Gracias
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