Triple P Seminar: The Power of Positive Parenting - Registrant Information
Wednesday, January 15, 2025: 3:00-4:30
Parent's Name
*
Parent's Age Range
*
Younger than 20
20-29
30-39
40-49
50-59
60-69
70 or older
Prefer not to answer
Parent's Race (select all that apply)
*
African American (Black)
American Indian or Alaska Native
Native Hawaiian or other Pacific Islander
Hispanic
White
Other
Prefer not to answer
Parent's Ethnicity
*
Hispanic
Non-Hispanic
Prefer not to answer
Parent's Mailing Address
*
Parent's Zip Code
*
Parent's Email Address
*
Parent's Cell Phone Number
*
Do you want to register an additional parent?
*
Yes
No
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Parent's Name
*
Parent's Age Range
*
Younger than 20
20-29
30-39
40-49
50-59
60-69
70 or older
Prefer not to answer
Parent's Race (select all that apply)
*
African American (Black)
American Indian or Alaska Native
Native Hawaiian or other Pacific Islander
Hispanic
White
Other
Prefer not to answer
Parent's Ethnicity
*
Hispanic
Non-Hispanic
Prefer not to answer
Parent's Mailing Address (if different from Parent 1)
Parent's Zip Code (if different from Parent 1)
Parent's Email Address
*
Parent's Cell Phone Number
*
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Next
Child's Name
*
First Name
Last Name
Child's Date of Birth:
*
-
Month
-
Day
Year
Date
Child's Age Range
*
0-11 months
12-23 months (1 year)
24-35 months (2 years)
36-47 months (3 years)
48-59 months (4 years)
60-71 months (5 years)
72 or more months (6 years or older)
Child's Race - select all that apply
*
African American (Black)
American Indian or Alaska Native
Native Hawaiian or other Pacific Islander
Hispanic
White
Other
Prefer not to answer
Child's Ethnicity
*
Hispanic
Non-Hispanic
Prefer not to answer
Child's Zip Code if different from caregiver:
Do you need to register another child?
*
Yes
No
Back
Next
Child's Name
*
First Name
Last Name
Child's Date of Birth:
*
-
Month
-
Day
Year
Date
Child's Age Range
*
0-11 months
12-23 months (1 year)
24-35 months (2 years)
36-47 months (3 years)
48-59 months (4 years)
60-71 months (5 years)
72 or more months (6 years or older)
Child's Race - select all that apply
*
African American (Black)
American Indian or Alaska Native
Native Hawaiian or other Pacific Islander
Hispanic
White
Other
Prefer not to answer
Child's Ethnicity
*
Hispanic
Non-Hispanic
Prefer not to answer
Child's Zip Code if different from caregiver:
Do you need to register another child?
*
Yes
No
Back
Next
Child's Name
*
First Name
Last Name
Child's Date of Birth:
*
-
Month
-
Day
Year
Date
Child's Age Range
*
0-11 months
12-23 months (1 year)
24-35 months (2 years)
36-47 months (3 years)
48-59 months (4 years)
60-71 months (5 years)
72 or more months (6 years or older)
Child's Race - select all that apply
*
African American (Black)
American Indian or Alaska Native
Native Hawaiian or other Pacific Islander
Hispanic
White
Other
Prefer not to answer
Child's Ethnicity
*
Hispanic
Non-Hispanic
Prefer not to answer
Child's Zip Code if different from caregiver:
*
Back
Next
How did you learn about this Triple P Positive Parenting Program Seminar? Select all that apply:
Friend
Website/Social Media
Flyer or Brochure
Newspaper
Agency/Referral
Other
PHOTO/MEDIA RELEASE
*
I give consent to allow Smart Start of Davie County to photograph my child(ren) and/or me. I understand that these images may be used in the media, newsletter, or on Smart Start’s website.
I DO NOT give consent for my child(ren) and/or me to be photographed by Smart Start of Davie County.
Smart Start of Davie County loves to share success stories with our board, grantors/funders, and other relevant groups. If you share a story with us, are you willing for us to share it with these groups (no specific/identifying descriptors would be used in the sharing of your success story)?
*
YES, I give Smart Start of Davie County permission to share my success stories.
NO, I would prefer not to have success stories about me published at this time.
By signing below, I affirm that the information I submitted in this registration form is accurate.
*
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