Registrant Name *

First Name

Last Name

Phone *

(###)

###

####

Which of the following best describe your home in its relationship to children? *

Note: Only households that have children under 6 living in them and/or homes where they regularly spend time

There is at least one child under the age of six (6) living in my home

There is a child / children under the age of 6 that regularly spends time in my home

There are no children that regularly spend time in my home (ineligible)

Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Which neighborhood do you live in? *

Note: In order to be eligible for this round, your home must be located in one of the following neighborhoods.

Arlington Heights

Broad Acres

Broadmoor Place

Magnolia Grove

Soria City

Other (ineligible)

Do you own or rent? *

I own my home.

I rent my home.

Would you be willing to host the workshop in your home? *

Note: A small stipend will be provided to the host.

Yes

No