Parent/Caregiver Enrollment Form

Name *

Gender *

Male

Female

Age *

Agency Address *

City *

State/Province *

Zip/Postal Code *

Email Address *

Phone *

Would you like to receive text messages regarding County Council activities and events? *

Yes

No

How did you hear about the County Council for Young Children (CCYC)? *

Would you need child care in order to attend meetings? *

Yes

No

Do you have transportation to attend County Council meetings? *

Yes

No

When would be the best time to schedule meeting? *

mornings

evenings

weekends

Would you need special accommodations to attend the meeting? *

None needed

hearing impaired

visually impaired

Other physically challenges please specify Other physically challenges please specify

Would you need translation services to support your participation in the Council? *

Yes

No