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Registration

Do you have access to: (Check all that apply.)
Do you have experience with courts/justice system/CYS?
Have you received financial aid in the past year? (TANF, SNAP, WIC, FMLA, SSI/SSDI, HUD/Section 811, LIHEAP, Military veteran pension, benefit, disability, unemployment compensation, tuition assistance)
Have you ever been incarcerated?

LISTENING SESSION CONSENT
As part of my participation in the Listening Session with Fathers and Families Living in Rural Pennsylvania, and the Outskirts of Urban and Suburban Communities, I understand participation is voluntary, and that I may cease participation at any time. I acknowledge that my participation is confidential. Reports about the listening session will protect participants’ privacy by excluding names and personally identifiable information, except where consent is granted below for photo and interview. I understand that there will be an audio recording to create a transcript and to analyze the information provided by participants.

I agree to participate in the listening session:

PHOTO AND INTERVIEW CONSENT
As part of my participation in the Listening Session with Fathers and Families Living in Rural Pennsylvania, and the Outskirts of Urban and Suburban Communities, I consent to the Administration for Children and Families (ACF) and its partners taking and using my image in photographs, film, or videos about the listening session. I waive any right to inspect and approve the finished materials, their use, or such copy as may be used.

I agree to be photographed:
I agree to be interviewed:
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