Clone of Kicks and Culture

1
Which event are you registering for?* This field is required.
Please Select
Please Select
Melanin Spectrum Celebration
BIPOC Family Wellness Event
2
Your Name* This field is required.By entering your name you confirm that you give permission for the above child to attend this workshop
First Name
Last Name
3
How many children and teens will be coming with you?* This field is required.Please enter the number of children and teens attending with you in each age range.
4
Your relationship to the children and teens who will be attending with you* This field is required.Please select all that apply.
Bio Parent
Grandparent
Step Parent
Aunt or Uncle
Adoptive Parent
Sibling
Foster Parent
Adult Friend
State Social Worker
Other
5
Your email* This field is required.
example@example.com
6
Your Phone Number* This field is required.
Include area code
7
Your Year of Birth* This field is required.
8
Your Races and Ethnicities (select all that apply)* This field is required.
Asian/Asian-American
Black, African, or African American
Indigenous to the Americas/American Indian/Alaska Native
Middle Eastern or North African
Native Hawaiian/Pacific Islander
White/European
Latina/o/x/e
Other
9
Your Gender (select all that apply)* This field is required.
Transgender (doesn't identify as gender assigned at birth)
Cisgender (does identify as gender assigned at birth)
Female
Male
Non-Binary
Agender
Two-Spirit
Fa’afafine
Fa’afatama
Questioning or unsure
Prefer not to say
Unknown
Other
10
Will another adult be attending with you?* This field is required.
No.
Yes, one additional adult will be attending with me.
Yes, more than one additional adult will be attending with me.
11
Second Adult's Name* This field is required.By entering your name you confirm that you give permission for the above child to attend this workshop
First Name
Last Name
12
Second Adult's relationship to the children and teens who will be attending* This field is required.Please select all that apply.
Bio Parent
Grandparent
Step Parent
Aunt or Uncle
Adoptive Parent
Sibling
Foster Parent
Adult Friend
State Social Worker
Other
13
Second Adult's email* This field is required.
example@example.com
14
Second Adult's Phone Number* This field is required.
Include area code
15
Second Adult's Year of Birth* This field is required.
16
Second Adult's Races and Ethnicities (select all that apply)* This field is required.
Asian/Asian-American
Black, African, or African American
Indigenous to the Americas/American Indian/Alaska Native
Middle Eastern or North African
Native Hawaiian/Pacific Islander
White/European
Latina/o/x/e
Other
17
Second Adult's Gender (select all that apply)* This field is required.
Transgender (doesn't identify as gender assigned at birth)
Cisgender (does identify as gender assigned at birth)
Female
Male
Non-Binary
Agender
Two-Spirit
Fa’afafine
Fa’afatama
Questioning or unsure
Prefer not to say
Unknown
Other
18
For the additional adults who will be attending: please provide their name, email address, phone number, relationship to the children, year of birth, race & ethnicity information, and gender information.* This field is required.
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Ok
19
Does anyone who will be attending have any food allergies or dietary restrictions or needs? If so, please describe.* This field is required.
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Large
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Small
Ok
Ok
20
Does anyone who will be attending have any access needs? If so, please describe.* This field is required.
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Small
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Ok
21
Number of family members 0-17 years old?* This field is required.
22
Number of family members 18-24 years old?* This field is required.
23
Your Zip Code* This field is required.
24
Does anyone in your family (select all that apply):* This field is required.
Live in Seattle
Work in Seattle
Go to school in Seattle
No one in our family lives, works, or goes to school in Seattle
25
What language(s) would you like to receive services in?* This field is required.Select all that apply
English
Other
26
What language(s) does your family speak at home? (select all that apply)* This field is required.
English
አማርኛ/Amharic
ភាសាខ្មែរ / Khmer
Af-Soomaali / Somali
American Sign Language
Anishinaabemowin / Anishinaabe
Chahta' / Choctaw
Diné Bizaad / Navajo
dxʷləšucid / Lushootseed
Español / Spanish
Filipino
French
Gagana faʻa Sāmoa / Samoan
Lakȟótiyapi / Lakota
Lingala
Łingít / Tlingit
língua portuguesa / Portuguese
Ōlelo Hawaiʻi / Hawaiian
Sahaptin / Yakima
Siksikáí'powahsin / Blackfoot
Tiếng Việt / Vietnamese
vosa vaka-Viti / Fijian
xʷləmi tʃɔsən / Lummi
हिन्दी / Hindi
한국인 / Korean
廣東話 / Cantonese Chinese
普通话 / Mandarin Chinese
Other
27
Household Income* This field is required.This helps us advocate to funders to fully fund our parent support groups!
$20,000 or less
$20,000 - $40,000
$40,000 - $60,000
$60,000 - $100,000
$100,000 - $200,000
Over $200,000
28
Number of People in Your Household* This field is required.
29
How did you find FOCS (select all that apply):* This field is required.
I am a returning FOCS participant
Paper flyer
Word of mouth
Another organization
Social media
Healthcare worker
Google search
Other
30
Data Use Agreement* This field is required.FOCS reports some demographic data and outcomes to our grantors and in our annual reports for the purposes of program evaluation, accountability, and to increase the likelihood of renewed funding. FOCS reports aggregated data only and will never disclose any personal or identifying data without gaining additional written consent.
31
Would you like to get email updates from FOCS?* This field is required.Select 'yes' to subscribe to our monthly newsletter
Yes!
No, thank you.
32
Would you like to receive reminder texts for the programming you are registering for?* This field is required.Select 'yes' to subscribe to our monthly newsletter
Yes!
No, thank you.
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