Day 2 Day Dads: A Responsible Fatherhood Program
Participant Referral and Intake Form

Email: dads@frcsa.org
Mail: 3825 Barrett Dr. Suite 104 Raleigh, NC 27609
Phone: 919-834-9300 ext. 210 Fax: 1-866-312-5783

How did you hear about our program?

TV/RadioFacebook/InstagramFlyerCommunity EventFriendFamilyOther

Best Way to Reach You:

PhoneEmailText

Race:

African American/BlackWhiteAsian American Indian/Alaskan NativeMore Than One Race

Ethnicity:

Non-HispanicHispanic

Employment Status

Full-timePart-timeRetiredStudentDisabledSeasonalUnemployedSelf-employed

I can attend a 2-hour workshop during these times of day (check all that apply):

Morning (9am -11am)Afternoon (12pm - 3pm)Evening (4pm - 9pm)

I can attend a workshop in the following counties:

DurhamWakeEdgecombe