Talk With Your Baby Registration
Location: St Joseph Public Library Date: June 13th- August 8th
Attendee Information
Your Name
*
Mr.
Mrs.
Miss.
Prefix
First Name
Last Name
Contact Number
*
This number will be used for class reminders/updates
Format: (000) 000-0000.
Email Address
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name and age of children (ages 0-3)
if expecting, please provide due month
Date of birth (children 0-3)
-
Month
-
Day
Year
Date
Which of the following best describes parent/guardian
*
Please Select
Black/African American
Hispanic/Latino
White/Caucasian
Native American or Alaskan Native
Asian or Pacific Islander
Multiracial
A race/ethnicity not described
Does your household qualify for benefits including Medicaid, SNAP, WIC, or TANF
*
Yes
No
Is there more than one language spoken in the child's home?
Yes
No
Will you have a guest with you?
Yes
No
Guest Name
Mr.
Mrs.
Miss.
Prefix
First Name
Last Name
Would you like information on other programs offered at the Robinson Community Learning Center (example: preschool, after school programs, etc.?)
*
Yes
No
Submit
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