Child Information
Rows
Name
Age
Gender (optional)
Children 1
Children 2
Children 3
Children 4
Children 5
Children 6
Children 7
Children 8
Parent/Caretaker Information
*
Name
Relationship to Child
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary language spoken in home?
*
Play information
Is the child considered to be typically developing?
Please Select
Yes
No
If no, please elaborate?
Has the child received any diagnosis(es) that affect his or her play?
Is there other Information pertaining to the child that we should know in order to make the best toy selections for him or her?
Demographic information
This information is NOT required. It only helps us ensure that we are serving a diverse group of families and targeting our efforts accordingly.
Chils's Ethnicity origin (or Race)
Highest completed education level in household:
Please Select
No Schooling completed
Some High School
Trade/Technical/Vocational Training
Associate's Degree
Bachelor's Degree
Master's Degree
Professional Degree
Doctorate Degree
Annual household income:
Please Select
$25,000
$25,000-$50,000
$50,000-$100,000
$100,000
Household composition
Please Select
Single parent
Married parents
Foster home
Grandparents
Other
How did you hear about Project Play?
Submit
Should be Empty: