Parent/Guardian Information

Last Name *

First Name *

email address *

Telephone Number *

Address *

Zip Code *

Household Type

Single Parent - Male

Single Parent - Female

Two Parents

Other

Clear selection

Ethnicity

Hispanic or Latino

Not Hispano or Latino

Clear selection

Race

Asian

American Indian or Alaska Native

White

Native Hawaiian or Other Pacific Islander

Black or African American

Other:

Clear selection

Have you received prior Covid financial assistance? *

Yes

No

I Don't Know

Are you willing to speak with a researcher, child advocate or reporter about your participation in this program? *

Yes

No