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Sign Up for Strong Couples - Strong Children

You are eligible to participate if you:
  • Are 18 years or older
  • Are an unmarried couple livingt in Durham County, NC
  • Are expecting a baby, or have a baby 3 months old or younger
    - it's okay if this is not your first pregnancy,
    we accept couples with older children in the household
  • Have a combined income of under $40,000
  • Are hoping to stay together


Name (First and Last):

Gender: Male Female

Phone 1:     Phone 2:

Street Address:
       

City:     State:     Zip:

Email Address:

Name of Partner:

Phone 1:     Phone 2:

1. Are you at least 18 years of age? Yes No

2. Are you in an unmarried relationship? Yes No

3. Is your partner* at least 18 years of age? Yes No
   [*Note: the partner does not have to be the father of the child.]

4. Are you and your partner* expecting a child or have had a child within the last 3 months? Yes No

5. Do you hope to be together with your partner in a year or two? Yes No

6. Do you speak and understand either English or Spanish? English Spanish Both Neither

7. Is there now or has there been any recent abuse in your current relationship? Yes No

8. How did you hear about the program? (Check all that apply)
    No previous knowledge of the program
    Community event/ festival booth
    TV
    Radio (station? )
    Internet search/ SC-SC website
    Daily newspaper (name? )
    Other print ad (specify: )
    Bus poster
    Other poster/ tear-off
    Current or former participant
    Other (word of mouth, friend, relative)
         please specify:

9. Do you and your partner currently reside in Durham, NC? Yes No