Immunize Kansas Coalition | Parent Group Interest Survey

IKC Parents & Families Interest Survey

Please complete this form to let us know of your interest in learning more about and/or joining the IKC Parents & Families group.

Question Title

* 1. Name

Question Title

* 2. Mailing Address

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Question Title

* 3. Email Address

Question Title

* 4. Phone Number

Question Title

* 5. This number is...

Home

Work

Cell

Question Title

* 6. How did you hear about the IKC Parents group?

Health provider

Social media

Family, friend, or co/worker

Other (please specify)

Question Title

* 7. Primarily, we would like to connect parents and develop community through a closed IKC Parents Facebook group, moderated by IKC Board members and staff. Do you currently have a Facebook account?

Yes

Yes, but I would not like to be part of the IKC Parents Facebook group.

No, but I would consider getting one to be part of the IKC Parents Facebook group.

I would like to connect but prefer not to use social media.

Question Title

* 8. Do any of these other activities interest you?

Participating in a webinar, podcast, or online Q&A session for parents, featuring expert panelists from the IKC Board

Attending a portion of an IKC meeting (in-person or phone) for a parent-specific discussion

Subscribe to and engage in conversations on an email list-serv

Participate in advocacy and education events in support of immunizations

Other (we're open to your ideas!)

Question Title

* 1. Name

Question Title

* 2. Mailing Address

Question Title

* 3. Email Address

Question Title

* 4. Phone Number

Question Title

* 5. This number is...

Question Title

* 6. How did you hear about the IKC Parents group?

Question Title

* 7. Primarily, we would like to connect parents and develop community through a closed IKC Parents Facebook group, moderated by IKC Board members and staff. Do you currently have a Facebook account?

Question Title

* 8. Do any of these other activities interest you?

Question Title

* 9. What would you want or expect to get out of participating in the IKC Parents group?