Great Start Parent Coalition (GSPC) Questionnaire

Name

Address

School District

Phone Number(s)

Email Address

Can we add you to the GSPC email list? Yes No

Answering the following questions does not determine if you become a member of the GSPC, it is merely a way to show that our parents represent the diversity of the community. Only answer the questions that you feel comfortable with.

Marital Status: Married Single Divorced Widowed
Racial Ethnicity: White Black Hispanic Other/Mixed Race
Do You Receive: WIC Medicaid Food Stamps SS/Disability

 

Children

Name: DOB: Age:

Name: DOB: Age:

Name: DOB: Age:

Name: DOB: Age:

 

Please list any parent groups/associations you have been involved in.

Please list your interests, needs, strengths, concerns and priorities regarding
your children.