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DEMOGRAPHICS FORM (RESOURCE PARENTS)

To be enrolled to take online classes at http://www.e-learn.pitt.edu, you will need to be registered for Encompass, our organization's database to track and report trainings in Child Welfare held across PA. Here you can fill out the demographics form as a Resource parent and submit to send this electronically to our staff.

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Name:
Start Date:
Email:
Phone:
Birth Date:
Last 4 Digits of SSN#:
Gender: Male Female
County of Residence:
Agency Name:
Optional: This information helps us to better plan trainings, conferences and anticipate the needs of the Pennsylvania's resource parents. Your needs are important to us so we want to be able to provide services that will meet these needs.
Race: Black/African American
White/Caucasian
Asian
American Indian/Alaskan Native
Native Hawaiian/Pacific Islander
Hispanic/Latino
2 or More
Other
Language: Are you able to provide services to children/families in a language other than English? Yes No
Current Highest Educational Degree Less Than High School
High School Diploma or GED
Associates degree (indicate Major Code)
Bachelor's degree in Social Work
Bachelor's Degree - other: (indicate Major Code)
Master's degree in Social Work
Master's Degree - other: (indicate Major Code)
Doctoral Degree
ELEARN Yes No
Send me my ELEARN username and password to the email listed above