Father's On Purpose, For A Purpose Men's Wellness, and Back to School Event

1

Name* This field is required.Please include your initials if you don't feel comfortable putting your name.

First Name

Last Name

2

Email* This field is required.

example@example.com

3

Which role best identifies you in your household?

Father/Father Figure

Mother/Mother Figure

Other Caregiver (Grandparent, Foster Parent)

Youth/Child

4

What Gender do you identify yourself as?

Female

Male

Other

7

How many school-aged children live in your home, or you provide care for?

8

What is your Zip Code?

9

What is your highest level of education?

Elementary or Middle School

High School Graduate or Equivalent

Some College / Trade Schools or Vocation

College Graduate

Master's and Above

11

If other for question 11, please specify

12

What are some barriers that men have for accessing resources or participating in community events?

Transportation

Uninterested in what is being offered.

Don't need the service or resource that is being offered.

The cost is too much / not affordable

The times offered don't fit into my schedule.

Staff needs to be more helpful and friendly.

13

When is the last time you went to the doctor for a wellness check, prostate exam, or other checkup not related to an injury?

Within the month

Less than 6 months

Less than a year

Less than 5 years

Over 5 years

14

Please share anything you want community providers to know about how to engage and retain males/fathers in community programs.