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Opening Doors
Building a Better Future Through Parent Leadership
Opening Doors Pre Survey
Date: (MM/DD/YYYY)
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First Name:
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Last Name:
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Last four digits of Social Security Number:
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Address:
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City:
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State:
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Zip:
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Primary Phone Number:
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Email Address:
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Age:
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Ethnicity:
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American Indian/Alaska Native
Asian
Black/African American
Multi-Racial
Native Hawaiian or other Pacific Islander
White
Other
I consider myself to be:
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Hispanic
Non Hispanic
Are you a veteran?
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Yes
No
Monthly Income:
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Gender:
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Male
Female
Trans Female
Trans Male
Gender non-conforming
Other
Marital Status:
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Married
Partnered
Single
Divorced
Widowed
Separated
Family Housing:
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Own
Rent
Shared housing with relatives/friends
Temporary (shelter, temporary with friends/relatives)
Homeless
Family Income:
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$0-$10,000
$10,001-$20,000
$20,001-$30,000
$30,001-$40,000
$40,001-$50,000
More than $50,000
Highest level of Education:
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Elementary or junior high school
Some high school
High school diploma or GED
Trade/Vocational Training
Some College
2-year college degree (Associate's)
4-year college degree (Bachelor's)
Master's degree
PhD or other advanced degree
Which, if any, of the following do you currently receive? (check all that apply)
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Food Stamps
Medicaid (State Health Insurance)
Earned Income Tax Credit
TANF
Head Start/Early Head Start Services
None of the above
Who referred you to the Opening Doors Program?
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Are you recommended or required by the referral to take this class? (If yes, please consider adding your referral to the program release)
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Yes
No
N/A
Will You Need Transportation Assistance:
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Yes
No
N/A
Any Language Barriers?
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Yes
No
Will you be attending this class with another parent/custodian/guardian who has signed up for Opening Doors? (Separate Enrollment is required)
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Yes
No
Name:
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Relationship:
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Phone Number:
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Email:
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Please upload a Picture of your ID/Driver's license
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How many children under 18 are in your household?
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1
2
3
4
5
6
7
8
9
10
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