With what race/ethnic group do you most identify? *
What is the highest level of education that you have completed?
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What is your total family income? (please note: Program services are available to families regardless of income)
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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.
Name of Child #1
Your answer
Gender
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Name of Child #2
Your answer
Gender
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Address of Children's Residence
Your answer
With what race/ethnic group do you most identify? *
Name of the school your children are attending *
Your answer
Please type: GyG85# (This code is to verify you are human.) *
Your answer
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