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MAMA Application
We are excited to have you be part of the MAMA Project! Please answer the following questions and someone will contact you.
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* Indicates required question
Email
*
Your email
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:
cell
home
work
okay to use text message
Phone # 2:
Your answer
Phone # 2 is:
cell
home
work
okay to use text message
e-mail address:
Your answer
What is the best way to contact you?
*
Phone call
Text message
e-mail
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)
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.
Yes, I would use child care
No, I would not use child care
Clear selection
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?
*
Transportation
Work
Health (mental, physical)
Child care
Other family obligations
Lack of support from family or friends
Location or meeting time (if you already know them)
None
Other
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)
*
1
2
3
4
5
6
7
8
9
10
I can attend at least 14 out of 17 classes
*
Yes
No
Not sure
I can attend at least half of the monthly support meetings after the class that meets twice a month (total of 8).
*
Yes
No
Not sure
I heard about this program from: (Please check all that apply)
The news
Facebook
A previous participant of the program
A flyer or poster
Other
What school or schools do your children attend?
Your answer
If you have questions, please contact Pati Monterrey at Office: 520.724.7888 or e-mail her at
pati.monterrey@pima.gov
Your answer
Thank you! Comment:
Your answer
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