100%

Interest in Participating Form

Questions marked with a * are required

Zero Breast Cancer is seeking girls ages 5-7 and their parents/caregivers for feedback during the development of a healthy activity program. Girls and their parents/caregivers will provide feedback on if the activities and booklet are fun, engaging, appropriate, educational and useful.

Parents/caregivers will receive $50 total for the first session after completing a 10 minute pre-call survey and 15 minute Zoom or phone call, with their girl present for about half of the call. Participants can decide whether to continue to provide feedback after the first call for up to $500 total compensation through June 2022.

We are especially looking for girls from all backgrounds in Marin County, CA, as well as Daisy Girl Scouts. If your girl is a Daisy, please specify that in the comments section.

Preference will be given to girls eligible to receive free or reduced price school lunch and living in select Northern CA counties.

Please complete the following form to let us know you are interested in participating.

Thanks!

Eligibility and preference criteria

	Yes	No	N/A
I am the parent or caregiver to a girl ages 5-7.	Yes	No	N/A

I am willing to complete a 15 minute survey and 30-60 minute Zoom or phone call with my 5-7 year old girl.	Yes	No	N/A

My 5-7 year old girl is eligible to receive free or reduced price school lunch. (Preferred but not required)	Yes	No	N/A

I live one of the following Northern California counties: Alameda, Butte, Contra Costa, Del Norte, Glenn, Humboldt, Lake, Marin, Mendocino, Napa, Santa Clara, San Francisco, San Mateo, Shasta, Siskiyou, Solano, Sonoma, Tehama, or Trinity.	Yes	No	N/A

About you and your girl

	'
What is your relationship to the girl age 5-7 that you will participate with?	'

How old is she?	'

What county do you live in?	'

What school does your girl attend?	'

What is your race/ethnicity?	'

What is your girl's race/ethnicity?	'

What language(s) do you speak?	'

What language(s) does your girl speak?	'

Contact Information

First Name

Last Name

Phone

Email Address

Do you have any questions or comments?