1-         Please check the entry that most closely matches your current status:             (Required items are marked with an *)
* Status:  *Zip Code:	Please select an item from the list below: Birth parent Kinship Caregiver Child Family Member Mental Health Practitioner Couselor/Social Worker Grandparent raising grandchildren Adolosecent / Young Adult Support group participant Support group leader/organizer A person generally interested in the issue of kinship legal guardianship Professional with a work-related interest in kinship (please describe) Other
*Other
2 -       Please fill out the following as completely as possible.  This information will            be critical in understanding who is in need of adoption services.   Again, we            assure you that any information you share will remain confidential.
Please specify your:
* Gender:	Select One Female Male
* Primary Race:
* Primary Language:
* Cultural Background
* Age group:	Select One Under 18 18 to 24 25 to 35 36 to 46 47 to 57 58 to 65 Over 65
* Marital Status:	Select One Single Married Divorced Single Parent Widowed Alternative Relationship Other
* List your current or anticipated needs: (At least one item must be checked)
	General information for persons impacted by kinship Understanding the kinship process Understanding the subsidy process Understanding the respite services Lifelong kinship issues Kinship children with severe behavioral needs Parenting of a kinship child / grandchild Educational needs of a kinship child Legal Custody Adoption Behavioral/emotional concerns of a kinship child peer support through mentoring Clinical services Medical services Legal Services Support groups for kinship Caregivers Support groups for kinship TEENS / CHILDREN Support groups for BIRTH PARENTS FAMILIES Other, please specify:
If you would like us to contact you directly regarding questions or concerns OR you wish to receive our ARCH Newsletter with periodic updates and event announcements, please share the OPTIONAL information below.
Name:
Daytime phone:
Evening phone:
Best time to call:
Address:
City and State:
Email address:
If you would like to receive the KinKonnect Newsletter, what format?   Please select from the list below: Email US Mail
Thank you again for responding to this survey!             AND for helping us help others!