Community Learning Registration Form NameThis field is for validation purposes and should be left unchanged.NamePhone NumberEmail Address Are you currently? Preconceptive (no prior pregnancies, no prior children, not pregnant) Pregnant or expecting Postpartum (delivered less than 6 months prior to today) Parenting an infant less than 6 months of age Parenting a child 6-11 months of age Parenting a child 12-18 months of age None of the above Declined to answer Select all that apply.What is your age?What is your Sex? Female Male Declined to answer Are you of Hispanic, Latino/a, or Spanish origin? No, not of Hispanic, Latino/a, or Spanish origin Yes, Mexican, Mexican American, Chicano/a Yes, Puerto Rican Yes, Cuban Yes, Another Hispanic, Latino/a, or Spanish origin Declined to answer Select all that apply.What is your race? White Black or African American American Indian or Alaska Native Asian Indian Chinese Filipino Japanese Korean Vietnamese Other Asian Native Hawaiian Guamanian or Chamorro Samoan Other Pacific Islander Declined to answer Select all that apply.Do you speak a language other than English at home? Yes No Declined to answer If yes, what language specifically?How well do you speak English? Very Well Well Not Well Not at all Declined to answer What is the highest grade or level of school that you have completed? No formal schooling 8th grade or less Some high school (Grades 9, 10, 11, & 12) High school diploma (Completed 12th grade) G.E.D. Some college or 2-year degree Technical or trade school Bachelor’s degree Graduate or professional school Declined to answer
