Exit District Dads Registration Form Question Title * 1. Name Question Title * 2. Date of Birth Date / Time Date Question Title * 3. Address Question Title * 4. Phone Question Title * 5. Email Question Title * 6. Emergency contact name Question Title * 7. Emergency contact Question Title * 8. Do you have any children currently enrolled in our ECE program at Martha's Table? Yes No Question Title * 9. Do you have access to a computer or tablet? Yes No Question Title * 10. How did you hear about District Dads? Court services DHS/ Social worker Church Martha's Table Media Event Friend Other (please specify) Question Title * 11. Enrollment type/ Referral Self-Enrollment Referring someone else Done
