Miami Children's Hospital


Community Services and Events
Community Education Survey

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Date
No. of children in your household	01234+
No. of children with disabilities in your household	01234 +
Ages of your children	0-1 yr2-6 yrs7-10yrs 11-1415-18 19-21
Your zip code
Email Address

Please tell us about topics you would like to see offered to families at MCH and your most preferred way of learning that topic.
Preferred method information delivery Please check one or more.	Topic
WorkshopBrochure EmailCD-Rom
WorkshopBrochure EmailCD-Rom
WorkshopBrochure EmailCD-Rom
WorkshopBrochure EmailCD-Rom

If a workshop is your primary education choice, please select your day and time preference.
	Monday to Friday - 10:00am to Noon Monday to Friday - 2:00pm to 4:00pm Monday to Friday - 4:00pm to 6:00pm Monday to Friday - 6:00pm to 8:00pm Weekend - 10:00am to Noon Weekend - Noon to 2:00pm Weekend - 2:00pm to 4:00pm Weekend - 4:00pm to 6:00pm

Please indicate your preferred location for educational programming. Please check all that apply.
Library - Indicate Location
School - Indicate Location
Miami Children's Hospital - Indicate Location
Miami Children's Hospital, South Dade Center - Perrine, FL
Miami Children's Hospital, Dan Marino Center - Weston
Other

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3100 S.W. 62nd Avenue • Miami, Florida 33155 • 305-666-6511 • Toll-free 1-800-432-6837 • Physician referral: 1-888-MCH-DOCS
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