Class Registration

Parenting Class:

Choose a Class:*

Group Triple PTeen Group Triple PFamily Transitions

Demographics:

ADULT 1

First & Last Name:*

Gender:*

Date of Birth:*

Race:*

Marital Status:*

ADULT 2

First & Last Name:

Gender:

Date of Birth:

Race:

Marital Status:

*Leave “adult 2” blank if registering alone.

Contact Information:

Phone Number:*

Address:*

Email:*

*Only one phone number, address,and email needed per household.

Family Information:

How many other adults live in the household other than you?*

Children:

CHILD 1

First & Last Name:*

Relation to you:*

Do they live with you?*

Age:*

Date of Birth:*

Race:*

Any concerns you’d like the instructor to know?

CHILD 2

First & Last Name:

Relation to you:

Do they live with you?

Age:

Date of Birth:

Race:

Any concerns you’d like the instructor to know?

CHILD 3

First & Last Name:

Relation to you:

Do they live with you?

Age:

Date of Birth:

Race:

Any concerns you’d like the instructor to know?

CHILD 4

First & Last Name:

Relation to you:

Do they live with you?

Age:

Date of Birth:

Race:

Any concerns you’d like the instructor to know?

CHILD 5

First & Last Name:

Relation to you:

Do they live with you?

Age:

Date of Birth:

Race:

Any concerns you’d like the instructor to know?

Referral Information:

Name of Person(s):

Agency (if applicable):

Contact information (if known):

Name of Person(s):

Agency (if applicable):

Contact information (if known):

Other Information:

Do you have any open DCS cases?
*If yes, please include case/cause number: This information is used for requesting referrals.

Do you have a restraining order against you or against someone else?
*If yes, please include the first and last name of the other party on the order.

Is there someone you would feel unsafe with if they joined the class?
*If yes, please include their first and last name.

Any medical conditions that would affect your ability to take the class?
*If yes, please list them.

Do you have any learning concerns that would affect your ability to take the class?
*If yes, please list them.

Emergency Contact Person:
*We will only contact this person if there is an emergency.

Parenting Class:

Choose a Class:*

Group Triple PTeen Group Triple PFamily Transitions

Demographics:

ADULT 1

First & Last Name:*

Gender:*

Date of Birth:*

Race:*

Marital Status:*

ADULT 2

First & Last Name:

Gender:

Date of Birth:

Race:

Marital Status:

*Leave “adult 2” blank if registering alone.

Contact Information:

Phone Number:*

Address:*

Email:*

*Only one phone number, address,and email needed per household.

Family Information:

How many other adults live in the household other than you?*

Children:

CHILD 1

First & Last Name:*

Relation to you:*

Do they live with you?*

Age:*

Date of Birth:*

Race:*

Any concerns you’d like the instructor to know?

CHILD 2

First & Last Name:

Relation to you:

Do they live with you?

Age:

Date of Birth:

Race:

Any concerns you’d like the instructor to know?

CHILD 3

First & Last Name:

Relation to you:

Do they live with you?

Age:

Date of Birth:

Race:

Any concerns you’d like the instructor to know?

CHILD 4

First & Last Name:

Relation to you:

Do they live with you?

Age:

Date of Birth:

Race:

Any concerns you’d like the instructor to know?

CHILD 5

First & Last Name:

Relation to you:

Do they live with you?

Age:

Date of Birth:

Race:

Any concerns you’d like the instructor to know?

Referral Information:

Name of Person(s):

Agency (if applicable):

Contact information (if known):

Name of Person(s):

Agency (if applicable):

Contact information (if known):

Other Information:

Do you have any open DCS cases?
*If yes, please include case/cause number: This information is used for requesting referrals.

Do you have a restraining order against you or against someone else?
*If yes, please include the first and last name of the other party on the order.

Is there someone you would feel unsafe with if they joined the class?
*If yes, please include their first and last name.

Any medical conditions that would affect your ability to take the class?
*If yes, please list them.

Do you have any learning concerns that would affect your ability to take the class?
*If yes, please list them.

Emergency Contact Person:
*We will only contact this person if there is an emergency.