PDG Application and Informed Consent for Play with Purpose groups

By filling out and signing this form, you are applying to participate in a Play with Purpose play group sponsored by National Center for Families Learning (NCFL). Play with Purpose is intended to help teach you how to interact with your child to improve your child’s development. If you participate, you must agree to certain things that are outlined below. Please fill out this form carefully and read completely before you sign at the end. Because this is a voluntary program, you may choose to discontinue your participation in the group at any time for any reason.
NOTE: The child’s parent or legal guardian must sign this form. If the primary caregiver applying is not the parent or legal guardian, both must sign this form.

1. Today's Date: *This question is required. This question requires a valid date format of MM/DD/YYYY.

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2. What organization are you participating with? *This question is required.

3. Who is completing this form? *This question is required.

Participating child's information

4. Child's Name *This question is required.

First Name:

Middle Name:

Last Name:

5. At the start of the program, the participating child will be aged *This question is required.

6. Child's Date of Birth: *This question is required. This question requires a valid date format of MM/DD/YYYY.

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7. How would you describe your participating child? *This question is required.Check all that apply.

Indigenous American or Indigenous Alaskan
Asian
Indigenous Hawaiian or Other Pacific Islander
Black or African-American
Hispanic or Latine/Latinx/Latin

White or Caucasian
Multiracial
Prefer to self-describe: Please enter an 'other' value for this selection. * This question is required.
Prefer not to respond

8. What is the participating child's sex? *This question is required.

9. What are the last 4 digits of the participating child's social security number?

Participating caregiver's information

10. Participating Caregiver's Name: *This question is required.

First Name:
Last Name:

11. Has this caregiver participated in a previous Play with Purpose group?

12. Participating caregiver's relationship to the participating child: *This question is required.

Please enter an 'other' value for this selection.

13. Participating caregiver's date of birth: *This question is required.

14. Participating caregiver's race/ethnicity: *This question is required.Check all that apply.

Indigenous American or Indigenous Alaskan
Asian
Indigenous Hawaiian or Other Pacific Islander
Black or African American
Hispanic or Latine/Latinx/Latin

White or Caucasian
Multiracial
Prefer not to respond
Prefer to self-describe: Please enter an 'other' value for this selection. * This question is required.

15. Participating caregiver's gender identity: *This question is required.

Please enter an 'other' value for this selection.

16. Last 4 digits of the participating caregiver's social security number:

17. Participating caregiver's preferred language: *This question is required.

18. Participating caregiver's email address: *This question is required. This question requires a valid email address.

19. Participating caregiver's mobile phone number: *This question is required.

20. Participating caregiver's home address:

Street Address

Apt/Suite/Office

City

State

Zip

21. Do you have access to the internet in your home? *This question is required.

22. Do you have: *This question is required.Check all that apply.

Computer?
Laptop?
Smart phone?
Tablet?

23. Please tell us how you heard about this program. *This question is required.

PDG Application and Informed Consent for Play with Purpose groups

Introduction