Parent/Guardian Information
First Name
Last Name
Phone Number
Email Address
Street Address
City
State
ZIP
County
Please select...
Adams
Allen
Bartholomew
Benton
Blackford
Boone
Brown
Carroll
Cass
Clark
Clay
Clinton
Crawford
Daviess
Dearborn
Decatur
Dekalb
Delaware
Dubois
Elkhart
Fayette
Floyd
Fountain
Franklin
Fulton
Gibson
Grant
Greene
Hamilton
Hancock
Harrison
Hendricks
Henry
Howard
Huntington
Jackson
Jasper
Jay
Jefferson
Jennings
Johnson
Knox
Kosciusko
LaGrange
Lake
LaPorte
Lawrence
Madison
Marion
Marshall
Martin
Miami
Monroe
Montgomery
Morgan
Newton
Noble
Ohio
Orange
Owen
Parke
Perry
Pike
Porter
Posey
Pulaski
Putnam
Randolph
Ripley
Rush
Scott
Shelby
Spencer
St. Joseph
Starke
Stueben
Sullivan
Switzerland
Tippecanoe
Tipton
Union
Vanderburgh
Vermillion
Vigo
Wabash
Warren
Warrick
Washington
Wayne
Wells
White
Whitley
County Email
Please tell us your preferred language so we can provide accommodations.
Please select...
English
Spanish
Amharic
Arabic
Chinese
Dutch
French
German
Greek
Gujarati
Haitian Creole
Hawaiian
Hebrew
Hindi
Igbo
Irish
Italian
Japanese
Korean
Malayalam
Myanmar (Burmese)
Pashto
Polis
Portuguese
Punjabi
Russian
Swahili
Swedish
Ukrainian
Vietnamese
Yoruba
Child Information
Do you have a child(ren)?
Yes
No
What is your relationship to the child(ren)?
Parent
Guardian
Grandparent or Great-Grandparent
Foster Parent
Family Relative
Other
How old is (are) your child(ren)? Select all that apply:
Aged 0 - 2
Aged 3 - 5
Aged 6 - 9
Aged 10 - 13
Aged 14 - 17
Over 18
Family Services
Which of these services have you or your family used? Select all that apply:
Child care (currently attends or has attended a child care program)
TANF, SNAP and/or WIC
Child Care Assistance (such as CCDF, On My Way Pre-K or Head Start or Early Head Start)
Early intervention for developmental concerns (such as First Steps) or special education services
Immigrant or refugee services or English as a second language (ESL) classes
None of the Above
Meeting Preferences
Why are you interested in joining Indiana's Family Advisory Council?
Do you prefer in-person or virtual meetings?
Please select...
In-person
Virtual
What is the longest you are willing to travel?
Please select...
15 Minutes
30 Minutes
45 Minutes
1 Hour
Do you have reliable internet and an internet-connected device (computer/tablet) for virtual meetings?
Yes
No
Are you able to attend a one-hour meeting every other month for 12 months (6 meetings total)?
Yes
No