Family Involvement Committee Interest Form

KCICC Family Involvement Committee Interest Form

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* 1. Name (First and Last) Mailing Address, Email, Phone Number

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 2. How do you identify?

American Indian or Alaskan Native

Asian

Native Hawaiian or other Pacific Islander

Black or African American

Hispanic or Latin (X)

White

Prefer not to respond

Self-Identify

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* 3. Do you need an interpreter?

Yes

No

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* 4. If you need an interpreter, what is the language?

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* 5. Did your child(ren) ever receive Early Support for Infants and Toddlers, also known as Birth to Three services?

Yes

No

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* 6. Can you commit to 5 in-person meetings?

Yes

No

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* 7. Why are you interested in becoming a Family Involvement Committee member?