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Piko Pals Participant Questionnaire
Thank you for your interest in joining Piko Pals! At this time, we have availability for 10 parents at each of our 2 locations. Depending on demand, as well as scheduling and flexibility of all applicants, we may be able to place you in 1 of the 2 groups. Please fill out the following questionnaire. We will use the information you provide us to communicate with you, consider your preferences, and coordinate meeting times for your potential group. Congratulations on starting this new and exciting chapter in your life! Mahalo! - Piko Pals
Email address
First Name of Parent Participant
Your answer
Last Name of Parent Partcipant
Your answer
Street Address
Your answer
Zipcode
Your answer
Phone Number
Your answer
Preference for Communication/Updates (you may choose more than one option)
I am a:
Name of participating child: (okay if undecided)
Your answer
Expected birth date of participating child, or children if you have multiples: (month/date/year)
Your answer
Names and birth dates of other child(ren):
(Start with the youngest first, and separate children with commas)
Your answer
Are there any special accommodations that you or your child needs?
Your answer
Please list any allergies that you or your child have.
Your answer
Newborn Piko Pals, January-March 2017
Our newborn program will take place January-March in 2017. If we are able to place you in one of the two groups, you will meet weekly for 2 hours.
I prefer to meet
Would you be willing to host a meeting at your home? We could rotate meeting at Piko Pal homes as it adds a level of warmth to our meetings.
Would you like to have a sign-up to rotate bringing light snacks to meetings?
What time of day would you like to meet? (You may choose more than one option.)
I prefer to meet on: (You may choose more than one day.)
If we are able to place you in one of the two groups, is it okay to share your contact information (name, phone number and email) with other participants in your Piko Pal group?
If we are able to place you in one of the two groups, is it okay to take pictures of your participation in our program for use in future grant applications, publications, brochures, or other materials used to promote Piko Pals?
In the event that we have more applicants than spaces in the two groups, would you be open to being trained and supported as a Piko Pal facilitator to lead your own group? (Facilitators do not need to be experts. They do, however, have to be kind, compassionate, supportive, and nonjudgmental. They will introduce discussion topics, help with meeting coordination, and communicate with the Piko Pal Team.)
How did you hear about Piko Pals?
Your answer
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