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Conectere
Cohort Application
COMPLETE ESTE FORMULARIO EN ESPAÑOL
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Thank you for your interest in the
Conectere
program. This confidential application will be reviewed by members of the research team and you will receive a response by June 10.
* Indicates required question
Email
*
Your email
First Name:
*
Your answer
Last Name:
*
Your answer
City, State
*
Your answer
Best phone contact:
*
Your answer
Church Affiliation (name of congregation):
Your answer
Name of pastor(s):
Your answer
Preferred Language:
*
Your answer
Gender:
*
Female
Male
Non-binary
I prefer not to answer
Race: (check all that apply)
*
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
Other:
Required
Are you Hispanic or Latinx?
*
Yes
No
Age range of your child(ren):
(check all that apply)
*
Infant
Toddler
Preschool
Early Elementary
Late Elementary
Middle School
High School
Young Adult
Other:
Required
When your child(ren) is not in school or daycare, how many days per week do they spend with you, on average?
Less than 1
1
2
3
4
5
6
7
Clear selection
Are you a foster parent?
*
Yes
No
Is someone else who provides care for your child(ren) also applying to this cohort program? If so, please provide their name(s) below.
Your answer
How did you hear about
Conectere
?
*
Your answer
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