Jefferson County Communities That Care Input Group Sign-Up

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Thank you for your interest in attending an input group for Jefferson County Communities That Care and our Twelve Talks initiative. Each group will last for 1 hour, during which you will give your opinions on programs, materials, websites and/or outreach for youth and/or parents.

Depending on your age, your feedback session will be during one of the two following time slots on Wednesday, June 26, 2019:

Youth Parent/Guardian/Caregiver: 12:00pm - 1:00pm
Youth Aged 14-20 Years Old: 3:00pm - 4:00pm

Please fill out the following survey in its entirety. Adults and youth who attend feedback groups will receive a $20 Target gift card, food and gift items. Note: unfortunately, JCPH staff or coalition members are not eligible to receive a gift card.

Jefferson County Public Health
645 Parfet Street
Lakewood, CO 80215

First and last name *

Email address *

Phone number

To which of the following groups do you belong? *

Parent, guardian, or caregiver of youth aged 14-20 years old

Youth aged 14-20 years old

Which session would you like to attend on June 26th?

Parent/Guardian/Caregiver of a youth who is 14-20 years old: 12:00pm - 1:00pm

Youth Aged 14-20 Years Old: 3:00pm - 4:00pm

Clear selection

Which geographic location do you represent?

Lakewood

Wheat Ridge

Edgewater

Jefferson County, as a whole

Other:

Clear selection

Are you employed by Jefferson County Public Health? *

Jefferson County Public Health employees are not eligible for gift cards, but will receive food & promotional items.

Yes

Do you have any dietary restrictions?

Please email jcphctc@jeffco.us with questions or comments, or enter them below.

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms