Parent Caregiver First Name

Parent Caregiver Last Name

Email Address

Phone

Prefered Language

Child First Name

Child Last Name

Date of Birth (MM-DD-YYYY)

Child Gender Child Gender Male Female Not Specified or Non-Binary or Other

Child Race Child Race American Indian or Alaskan Native Black or African American Asian Hispanic or Latino Native Hawaiian or Other Pacific Islander White Two or More Races Not Specified

Child Ethnicity Child Ethnicity Hispanic or Latino Not Hispanic or Latino Not Specified

School District for Kindergarten Enrollment School District for Kindergarten Enrollment Columbus City Schools Groveport Madison Local Hamilton Local Reynoldsburg Southwestern City Whitehall City

How did you hear about the challenge? How did you hear about the challenge? Facebook Instagram A Community Partner (AFC, United Way, YMCA, etc.) Bright by Text Other

Other

Name

Email Address

Message