Clone of FOCS Newborn Registration

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Your First Name* This field is required.Please enter this information for the first parent/caregiver who will be attending.
2
Your Last Name* This field is required.Please enter this information for the first parent/caregiver who will be attending.
3
Your Email* This field is required.Please enter this information for the first parent/caregiver who will be attending.
example@example.com
4
Your Phone Number* This field is required.Please enter this information for the first parent/caregiver who will be attending.
Include area code
5
Your Races and Ethnicities (select all that apply)* This field is required.Please enter this information for the first parent/caregiver who will be attending.
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
6
Your Gender (select all that apply)* This field is required.Please enter this information for the first parent/caregiver who will be attending.
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
Unkown
Other
7
Your Year of Birth* This field is required.Please enter this information for the first parent/caregiver who will be attending.
8
How many of your children will be attending?* This field is required.Please include any children you are currently expecting..
1
2
3
4
5
9
First Child Attending - Name* This field is required.
10
First Child Attending - Date of Birth or Estimated Due Date* This field is required.
Date
Month
Day
Year
11
Second Child Attending -Name* This field is required.
12
Second Child Attending - Date of Birth or Estimated Due Date* This field is required.
Date
Month
Day
Year
13
Third Child Attending - Name* This field is required.
14
Third Child Attending - Date of Birth or Estimated Due Date* This field is required.Child 3
Date
Month
Day
Year
15
Fourth Child Attending - Name* This field is required.
16
Fourth Child Attending - Date of Birth or Estimated Due Date* This field is required.Child 4
Date
Month
Day
Year
17
Fifth Child Attending - Name* This field is required.
18
Fifth Child Attending - Date of Birth or Estimated Due Date* This field is required.
Date
Month
Day
Year
19
Does anyone who will be attending have any food allergies or dietary restrictions or needs? If so, please describe.* This field is required.
Huge
Large
Normal
Small
Ok
Ok
20
Does anyone who will be attending have any access needs? If so, please describe.* This field is required.
Huge
Large
Normal
Small
Ok
Ok
21
Potential Barriers to Program Participation (select all that apply)
Childcare
Transportation
Other
22
Number of family members 0-17 years old?* This field is required.
23
Number of family members 18-24 years old?* This field is required.
24
Your Zip Code* This field is required.
25
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
26
What language(s) would you like to receive services in?* This field is required.Select all that apply
English
Other
27
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
28
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
29
Number of People in Your Household* This field is required.
30
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
31
Undoing Racism / White Privilege Agreement* This field is required.FOCS holds space for discussion on race, identity, community, and equity with a foundation of undoing systems of oppression. Our programs are not a way to check a diversity box or to debate racism. Racism and white privilege exist. FOCS community is a place where BIPOC families come to feel safer. We center the narratives of BIPOC people and those most impacted by oppression. We believe in upholding our value of undoing racism. These are our experiences, and we are sharing the pain, trauma, and liberation of them so we can be equipped with tools to protect and inform our BIPOC children
32
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.
33
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.
34
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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