Parent Education Survey Name First Last Email PhoneZip Code Session TitleWhat was the name of the class you attended? Date Facilitator 1. Number of children in the household ages birth - 5 years old:2. Caregiver Type Mother Father Grandparent Foster Parent Child Care Provider Other (Please explain below) If you selected "Other", please explain: 3. Please select the response that reflects your honest opinion. - I gained knowledge and/or skills.Strongly AgreeAgreeDisagreeStrongly DisagreeI will use this information to better support my children and familyStrongly AgreeAgreeDisagreeStrongly DisagreeThe instructor demonstrated knowledge about the topic presentedStrongly AgreeAgreeDisagreeStrongly DisagreeOverall, I was satisfied with the trainingStrongly AgreeAgreeDisagreeStrongly DisagreeWere you informed of your client rights & responsibilities?YesNo4. What was the most helpful part of the session?5. What will you do differently (if anything) as a result of attending this session?6. How did you register for this class? Casa de los Niños Website Email Phone Other If you selected "Other", please explain: 7. Other CommentsPlease provide us with some information about you by checking the appropriate boxes.Race/Ethnicity: Please check the boxes that best describe your race and ethnicity. *Hispanic is considered an ethnicity, not a race. If you describe yourself as Hispanic you must also declare one race category. White Black/African American Asian American Indian/Alaskan Native Native Hawaiian/Other Pacific Islander Other Multi-Racial Do you consider yourself of Spanish/Hispanic/Latino Heritage?NoYesIncome LevelPlease select the income range that best describes the total income of your household: $0 - $9,999 $10,000 - $19,999 $20,000 - $29,999 $30,000 - $39,999 $40,000 - $49,999 $50,000 - $59,999 $60,000 - $69,999 Above $70,000 Including yourself, how many people are in your household?Age: 18-22 23-59 60-65 66-85 85+ Gender Male Female Check here if you are the female head of the household No response DisabilityCheck here if you have a disability. (Mental, behavioral, substance addictions, developmental and/or physical) Yes No 1. As a result of attending this parenting class I feel more confident in my abilities as a parent in supporting my child’s safety, health and well being. Yes No 2. As a parent I know how to find information and resources about child development and health as well as additional support for parents and families. Yes No If no, how can the Casa de los Niños Community Education & Outreach program better support your needs for social connections and need of supports?
