MAMA Application
We are excited to have you be part of the MAMA Project! Please answer the following questions and someone will contact you.
Email address *
Name: *
Your answer
Today's date: *
MM
/
DD
/
YYYY
Home address:
Your answer
City
Your answer
Zip code:
Your answer
Phone # 1:
Your answer
Phone # 1 is:
Phone # 2:
Your answer
Phone # 2 is:
e-mail address:
Your answer
What is the best way to contact you? *
Required
What is your date of birth?
Your answer
How many children do you have?
Your answer
What are your children's ages?
Your answer
Availability: When are you available? Please mark all the days/times when you are available on the space below.
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunnday
Morning (9 -12)
Afternoon (1-4)
Evening (4-7)
Comments regarding times when you are available.
Your answer
Child Care: We will do our best to provide a child care option.
If yes, which of your children need child care and what time of day?
Your answer
Barriers: We will do our best to support you in solving problems that could prevent you from showing up or participating in the program. Which (if any) issues do you think could affect your ability to attend t he program? *
Required
Other Barriers:
Your answer
What would you like to get out of the class?
Your answer
How excited are you about this class? (1= low.......10= high) *
I can attend at least 14 out of 17 classes *
I can attend at least half of the monthly support meetings after the class that meets twice a month (total of 8). *
I heard about this program from: (Please check all that apply)
What school or schools do your children attend?
Your answer
If you have questions, please contact Desiree Doten at Office: 520.724.7888 Cell: 520.406.1824 or e-mail her at desiree.doten@pima.gov
Your answer
Thank you! Comment:
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