Name:

email:

Phone:

You are the only parent?

• Yes
• No

How many kids do you have?

• 1
• 2
• 3 or more

How old are your kids?

• 1-3 years old
• 3-7 years old
• 7-11 years old
• 11-15 years old
• 15-18 years old

Who takes care of the kid(s) while you are at work?

• Husband / Wife
• Nanny
• Grandparents
• Kindergarten
• The After School
• He \ They stay alone

In which area do you live?

How did you find about this workshop?

Your message (what made you subscribe to this workshop?)