First 5/ Contra Costa Triple P Seminar Registration Form
Thank you for taking time to complete this registration form. Your answers will help us to learn more about and better serve you and your family. Surveys from all Triple P classes will be combined into a summary report for Triple P Funders, First 5 Contra Costa, and Contra Costa Mental Health Services (MHSA). Your name will be kept confidential and we will not ask about immigration status. Your responses will not affect any First 5 or MHSA services you receive. Thank you!
* Required
Email address
*
Your email
Class in which you are enrolling?
*
Triple P Seminar - one day class
Your Full Legal Name
*
Your answer
Gender
*
Female
Male
Prefer not to say
City of Residence
*
Your answer
Best Phone Number to Contact You
*
Your answer
With what race/ethnic group do you most identify?
*
African American/Black
American Indian/Alaska Native
Asian
Hispanic/Latino
Middle Eastern/North African
White
More than one
Other:
What are the ages of the children living with you? Please include the child/teen you have selected to focus on for this class and any other children or teens living in your home.
*
0-5 years
6-12 years
13-19 years
Other:
Required
What is the highest level of education that you have completed?
Attended grammar school (up to 6th grade)
Some middle or high school (no high school degree)
High School Degree or GED
Attended a two year college or vocational school
Received a Bachelor's Degree
Received an advanced degree (Master's Degree or PhD)
Don't know / Prefer not to say
Clear selection
What is your total family income? (please note: Program services are available to families regardless of income)
Monthly $6,251 or more = $75,001 or more Annually
Monthly $5,001 - $6,250 = $60,001 -$75,000 Annually
Monthly $3,751 - $5,000 = $45,001 -$60,000 Annually
Monthly $2,501 - $3,750 = $30,001 -$45,000 Annually
Monthly $1,251 - $2,500 = $15,001 -$30,000 Annually
Monthly $1,250 or less = $15,000 or less
Don't know / prefer not to say
Clear selection
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