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Conectere
Interest Form
COMPLETE ESTE FORMULARIO EN ESPAÑOL
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Thank you for your interest in the
Conectere
program. Completing this interest form will register you for our electronic mailing list. We may also contact you about specific resources and opportunities as they become available, including applying to our parent/caregiver cohorts.
* 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:
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
Are you:
*
Parent/Caregiver
Pastor
Congregational Leader
Children/Youth Ministry Volunteer
Community Leader
Educator
Other:
Required
If parent/caregiver, age range of your child(ren):
(check all that apply)
Infant
Toddler
Preschool
Early Elementary
Late Elementary
Middle School
High School
Young Adult
Other:
Are you a foster parent?
*
Yes
No
Is there anything more you want to share about your current parenting/caregiving experience?
Your answer
How did you hear about
Conectere
?
*
Your answer
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