Father's Feelings Enrollment Form - OhioGuidestone Research Portal

Electronic Agreement *

By checking this box, I agree to use electronic records and electronic signatures.

Staff name

First

Last

For staff use only

Date *

Enrollment Information

Participant name *

First

Last

Participant's date of birth *

Is your baby born yet? *

Yes
No

Baby's date of birth *

Baby's estimated due date *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Email *

Phone number *

I give permission for study staff to text me regarding study appointments at the above phone number *

Yes
No

I give permission for study staff to leave me voicemails regarding study appointments at the above phone number *

Yes
No

Emergency contact

First

Last

Emergency contact number

Demographic Information

Primary language spoken at home *

Are you of Hispanic/Latinx heritage? *

Yes
No

Race (please choose all that apply) *

If other, please explain *

Relationship status *

Are you married to the mother of your baby? *

Yes
No

Are you partnered to the mother of your baby? *

Yes
No

Are you divorced from the mother of your baby? *

Yes
No

Are you widowed from the mother of your baby? *

Yes
No

Are you separated from the mother of your baby? *

Yes
No

Education level *

If other, please explain *

Household Information

Annual household income *

Employment status *

If other, please explain *

Occupation/job *

Are or were you and/or your partner in the military? *

Yes, only me
Yes, only my partner
Yes, both me and my partner
No

Household family size (includes you, other adults, and children) *

Is the mother of your baby included in your household? *

Yes
No

Is your partner currently pregnant? *

Yes
No

Family housing situation *

Who do you co-parent with? *

If other, please explain *

My co-parent's relationship to my child(ren) is *

Examples: Mother, Father, Stepmother, Dad's girlfriend, Mom's partner, Grandmother, Aunt, Foster mother, etc.

Demographics of Children

How many children do you have?

Number of children: 0

Child 1

Child 1's age *

Child 1's gender *

Does child 1 live with you? *

Yes
No

Child 1's relationship to you *

If other, please explain *

Is child 1 of Hispanic/Latinx heritage? *

Yes
No

Child 1's race (please choose all that apply) *

If other, please explain *

Child 2

Child 2's age *

Child 2's gender *

Does child 2 live with you? *

Yes
No

Child 2's relationship to you *

If other, please explain *

Is child 2 of Hispanic/Latinx heritage? *

Yes
No

Child 2's race (please choose all that apply) *

If other, please explain *

Child 3

Child 3's age *

Child 3's gender *

Does child 3 live with you? *

Yes
No

Child 3's relationship to you *

If other, please explain *

Is child 3 of Hispanic/Latinx heritage? *

Yes
No

Child 3's race (please choose all that apply) *

If other, please explain *

Child 4

Child 4's age *

Child 4's gender *

Does child 4 live with you? *

Yes
No

Child 4's relationship to you *

If other, please explain *

Is child 4 of Hispanic/Latinx heritage? *

Yes
No

Child 4's race (please choose all that apply) *

If other, please explain *

Child 5

Child 5's age *

Child 5's gender *

Does child 5 live with you? *

Yes
No

Child 5's relationship to you *

If other, please explain *

Is child 5 of Hispanic/Latinx heritage? *

Yes
No

Child 5's race (please choose all that apply) *

If other, please explain *

Child 6

Child 6's age *

Child 6's gender *

Does child 6 live with you? *

Yes
No

Child 6's relationship to you *

If other, please explain *

Is child 6 of Hispanic/Latinx heritage? *

Yes
No

Child 6's race (please choose all that apply) *

If other, please explain *

Child 7

Child 7's age *

Child 7's gender *

Does child 7 live with you? *

Yes
No

Child 7's relationship to you *

If other, please explain *

Is child 7 of Hispanic/Latinx heritage? *

Yes
No

Child 7's race (please choose all that apply) *

If other, please explain *

Child 8

Child 8's age *

Child 8's gender *

Does child 8 live with you? *

Yes
No

Child 8's relationship to you *

If other, please explain *

Is child 8 of Hispanic/Latinx heritage? *

Yes
No

Child 8's race (please choose all that apply) *

If other, please explain *

Father’s Feelings Enrollment Form

Enrollment Information

Demographic Information

Household Information

Demographics of Children

Child 1

Child 2

Child 3

Child 4

Child 5

Child 6

Child 7

Child 8