Parenting During COVID - Participation Information

2. First Name

3. Last Name

5. Date of Birth
   Date of Birth

6. Ethnicity (Optional)

7. Language spoken at home

9. Phone Number

11. Address

13. City

14. State

15. Zip

17. Number of Kids in Home

18. Have you or your child received services through City of Fremont, Youth and Family Services before?

    1. Yes
    2. No

20. Date of Support Group (English Group)
    -- Select One --Tues. April 13 at 6:00 - 7:30 pmTues. April 20 at 6:00 - 7:30 pmTues. April 27 at 6:00 - 7:30 pm

    Please reserve date of attendance. You will receive an email with the link to enter the virtual support group. *Please let facilitator know if you plan to attend on a weekly basis.

22. What are your parenting concerns at this time?

24. Email Address *

26. Confidentiality Statement*

    Information shared during the virtual support group, Parenting During COVID, is confidential. Information will not be shared outside of our virtual meetings without your permission. However, disclosure is required by law when there is a reasonable suspicion of abuse or neglect of a child, an elder, or a dependent adult; when there is a reasonable suspicion that someone presents a danger of violence to others; or when someone is likely to harm him/herself unless protective measures are taken.

    1. Check box in agreement
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28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit Submit and Print

* indicates a required field