Honoring Our Strong Native Mother's Registration

Family Formation thru M.E.N.S. Project
REGISTRATION FORM
You must attend both workshops (Program and Curriculum Overview 6.16.21 and Home Repair Project 6.23.21) to qualify for the participation incentives. Please register your family that will participate so we can make sure we give you enough materials to do the project during the paint night workshop. A current Prevention Application must be received or on file to participate. If you haven't filled one out between now and last April then you probably need another one, please indicate so down below. It can be provided along with our short pre/post surveys and event evaluation. Those documents will be required and accepted on 5.7.21 at our Drive-Thru Event.
*Painting materials will need to be picked up from our office between 9am-4pm, 5.4 & 5.21, delivery is available on a needs only basis
Participating Mother*
First NameLast Name
Age (Optional)
Gender (optional)
MaleFemaleOther
Phone Number*
Area CodePhone Number
Email (to receive WebEx or Zoom link for workshops)*

Confirmation Emailexample@example.com
Address (so we can deliver if needed)*
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Do you need materials delivered? please only say yes if it is absolutely neccessary *
Do you want to register your children? (please only list those in your home that are on or will be on your prevention application)
Where did you hear about this virtual event?
FacebookRemindNewsletterFriend/FamilyOther
Do you have a current Prevention Application on file (submitted between March 2020 and now)?*
YesNot SureNoWhat is a Prevention Application?Other
Which OVCDC Site are you associated with?*
BakersfieldVenturaLake Isabella
NOTE: Prevention Applications, Pre/Post Surveys and Evaluation will be given when activity materials are picked up or delivered. Just be sure not to lose those 3 documents as they will be collected 5.7.21 at our Drive-Thru Event.
Any questions or comments?
Should be Empty:

Family Formation thru M.E.N.S. Project