PSF Registration Positive Solutions for Families Name * Required First Last Email * Required County of Residence * RequiredAllegany CountyAnne Arundel CountyBaltimore CityBaltimore CountyCalvert CountyCaroline CountyCarroll CountyCecil CountyCharles CountyDorchester CountyFrederick CountyGarrett CountyHarford CountyHoward CountyKent CountyMontgomery CountyPrince George's CountyQueen Anne's CountySomerset CountySt. Mary's CountyTalbot CountyWashington CountyWicomico CountyWorcester CountyAddress * Required Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Do you have access to a device (computer/tablet/phone) and internet in order to participate in a Zoom workshop? I have a device and access to the internet. I have a device, but no internet. I have internet, but no device. Ethnic Identity * Required Hispanic Non-Hispanic Racial Identity * Required White Black/African American Asian American Indian/Alaska Native Native Hawaiian/Other Pacific Islander American Indian/Alaskan Native and White Asian and White American Indian or Alaskan Native and Black/African American Other Multi-Racial Hispanic None of these apply to me Please Describe Your Racial Identity Would any accomodations be helpful for you? (e.g. closed captioning, etc) How many children are you parenting? * RequiredAge of Children (check all that apply) * Required Expecting Under 1 year 1-2 years old 2-3 years old 3-4 years old 4-5 years old 5 years old or older How well do you speak English? * Required Very Well Well Not Well Not at all Do you speak a language other than English at home? * Required Yes No Please list any other languages spoken: Is it a female headed household? * Required Yes No Have you been unhoused at any point in the past 5 years? * Required Yes No Are you currently residing in shelter? * Required Yes No Income Information - This information is required by the grant funder for demographic purposes but is kept confidential. No identifying information will be shared.How many people live in your household? 1 2 3 4 5 6 7 8 My household income is: * Required between $0-$22,100 between $22,100-$36,800 between $36,800-$55,950 more than $55,950 My household income is: * Required between $0-$25,250 between $25,250-$42,500 between $42,500-$63,950 more than $63,950 My household income is: * Required between $0-$28,400 between $28,400-$47,300 between $47,300-$71,950 more than $71,950 My household income is: * Required between $0-$31,550 between $31,550-$52,550 between $52,550-$79,900 more than $79,900 My household income is: * Required between $0-$34,100 between $34,100-$56,800 between $56,800-$86,300 more than $86,300 My household income is: * Required between $0-$36,600 between $36,600-$61,000 between $61,000-$92,700 more than $92,700 My household income is: * Required between $0-$40,120 between $40,120-$65,200 between $65,200-$99,100 more than $99,100 My household income is: * Required between $0-$44,660 between $44,660-$69,400 between $69,400-$105,500 more than $105,500 Section BreakSignatureI certify that the information given on this form is true and accurate to the best of my knowledge. I am aware that there are penalties for willfully and knowingly giving false information on an applicant for Federal, State or County funds, which may include immediate repayment of all Federal, State or County funds received and/or prosecution under the law. I understand that the information on this form is subject to verification by County, State or Federal personnel as part of compliance monitoring. I agree to provide, upon request, documentation on all income sources.