12/05/23 Family Partner Community Health Worker Panel

Personal Information

• * First Name:
• * Last Name:
• * Email Address:
• * Confirm Email Address:
• * Are you a parent / caregiver / family member / family partner of a child with emotional, behavioral, or mental health needs? Are you a peer leader who works with children and has lived experience? --Choose-- Yes No
• *

  Is this your first time attending a PPAL Workshop?

  • yes
  • no
• * ZIP Code:

• What racial background do you most identify with?

  • Asian American/ Pacific Islander
  • Biracial
  • Black/ African American
  • Hispanic/ Latinx
  • Indigenous/ American Indian
  • White/ Caucasian
  • Prefer Not To Answer