Motheread/Fatheread Colorado Parent Information Form

Agency/Organization Name ______

Motheread/Fatheread Facilitator Name(s) ______

Parent/Guardian Name- (or assigned agency number) / City of Residence / Zip Code
What language does your family speak in the home most often?
q  English / q  Spanish / q  Other ______
Does your family qualify for free or reduced-price lunch at school? (check one)
q  Free lunch / q  Reduced-price lunch / q  No, we do not qualify.
Child 1 / Child Name / Birth month (mm/yyyy) / Gender
q Male
q  Female
Is your child (please check only one)? / Is your child of Hispanic, Latino or Spanish origin?
q  Yes
q  No
q  White/Caucasian
q  Black/African American
q  Asian
q  American Indian or Alaska Native / q  Native Hawaiian/Pacific Islander
q  Multiracial
q  Unknown
q  Other (please specify)
What grade is your child in?
q  Infant (0-12 months)
q  Toddler (Over 12 months to under 3 years)
q  Preschool (3 years to under 4 years) / q  ECE (4 years to under 5 years)
q  Kindergarten (5-6yrs)
q  1st Grade / q  2nd Grade
q  3rd Grade
q  4th Grade or older
Child 2 / Child Name / Birth month (mm/yyyy) / Gender
q Male
q  Female
Is your child (please check only one)? / Is your child of Hispanic, Latino or Spanish origin?
q  Yes
q  No
q  White/Caucasian
q  Black/African American
q  Asian
q  American Indian or Alaska Native / q  Native Hawaiian/Pacific Islander
q  Multiracial
q  Unknown
q  Other (please specify)
What grade is your child in?
q  Infant (0-12 months)
q  Toddler (Over 12 months to under 3 years)
q  Preschool (3 years to under 4 years) / q  ECE (4 years to under 5 years)
q  Kindergarten (5-6yrs)
q  1st Grade / q  2nd Grade
q  3rd Grade
q  4th Grade or older
Mothered/Fatheread facilitators, please complete this section for the parent listed above:
Date Form Completed ______/______/______
Date of First Motheread/Fatheread Session Attended ______/______/______
Date of Last Motheread/Fatheread Session Attended ______/______/______
Child 3 / Child Name / Birth month (mm/yyyy) / Gender
q Male
q  Female
Is your child (please check only one)? / Is your child of Hispanic, Latino or Spanish origin?
q  Yes
q  No
q  White/Caucasian
q  Black/African American
q  Asian
q  American Indian or Alaska Native / q  Native Hawaiian/Pacific Islander
q  Multiracial
q  Unknown
q  Other (please specify)
What grade is your child in?
q  Infant (0-12 months)
q  Toddler (Over 12 months to under 3 years)
q  Preschool (3 years to under 4 years) / q  ECE (4 years to under 5 years)
q  Kindergarten (5-6yrs)
q  1st Grade / q  2nd Grade
q  3rd Grade
q  4th Grade or older
Child 4 / Child Name / Birth month (mm/yyyy) / Gender
q Male
q  Female
Is your child (please check only one)? / Is your child of Hispanic, Latino or Spanish origin?
q  Yes
q  No
q  White/Caucasian
q  Black/African American
q  Asian
q  American Indian or Alaska Native / q  Native Hawaiian/Pacific Islander
q  Multiracial
q  Unknown
q  Other (please specify)
What grade is your child in?
q  Infant (0-12 months)
q  Toddler (Over 12 months to under 3 years)
q  Preschool (3 years to under 4 years) / q  ECE (4 years to under 5 years)
q  Kindergarten (5-6yrs)
q  1st Grade / q  2nd Grade
q  3rd Grade
q  4th Grade or older
Child 5 / Child Name / Birth month (mm/yyyy) / Gender
q Male
q  Female
Is your child (please check only one)? / Is your child of Hispanic, Latino or Spanish origin?
q  Yes
q  No
q  White/Caucasian
q  Black/African American
q  Asian
q  American Indian or Alaska Native / q  Native Hawaiian/Pacific Islander
q  Multiracial
q  Unknown
q  Other (please specify)
What grade is your child in?
q  Infant (0-12 months)
q  Toddler (Over 12 months to under 3 years)
q  Preschool (3 years to under 4 years) / q  ECE (4 years to under 5 years)
q  Kindergarten (5-6yrs)
q  1st Grade / q  2nd Grade
q  3rd Grade
q  4th Grade or older