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PDG Application, Informed Consent, and Demographics for Family Literacy

Family Literacy Enrollment

By completing this form, you are enrolling in a Family Literacy program. This Family Literacy program is sponsored by National Center for Families Learning (NCFL). If you participate, you must agree to certain things that are outlined below. Please read the entire form before you sign at the end. You may choose to leave this program at any time for any reason.

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

Focus child's information

Any of your children ages 0-8 years may participate in the Family Literacy program. We will be collecting information about one of your participating children. We will call this child the "focus child".

2. Focus child's name *This question is required.

First Name:

Last Name:

3. Focus child's date of birth: *This question is required. This program is available for children ages birth through 8 years old. This question requires a valid date format of MM/DD/YYYY.

calendar

4. How would you describe your focus 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

5. What is your focus child's gender? *This question is required.

Please enter an 'other' value for this selection.

6. What are the last 4 digits of the focus child's social security number? (optional)

Participating parenting adult's information

7. Your name: *This question is required.

First Name:
Last Name:

8. How would you describe yourself? *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.

9. How would you describe your gender identity? *This question is required.

Please enter an 'other' value for this selection.

10. Last 4 digits of your social security number: (optional)

11. Your home address:(optional)

Street Address

Apt/Suite/Office

City

State

Zip

12. Your email address: *This question is required. This question requires a valid email address.

13. Your mobile phone number: *This question is required.

14. Which digital device(s) do you have at home? *This question is required.Check all that apply.

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