Name
*
First Name
Last Name
Email Address
*
Street Address
*
Apartment or Unit #
Zip Code
*
Phone
*
(###)
###
####
How did you hear about this class?
*
Court Brochure
Online Search
Family or Friend
Lawyer or Mediator
The fee for the class is $150. How will you be paying for the class?
*
Is there anyone who you do NOT want to attend the same class as you?
*
You have the right to attend the class together or separate from any individual.
If you do not want a specific person attending the class with you, include his/her name.
Have there been any safety concerns or domestic violence issues between you and your child(ren)'s other parent?
*
If YES, please explain.
Are there currently any active restraining orders, protective orders or no contact orders for either parent?
*
If YES, provide the type of order and the first AND last name of all individuals in the order.
If YES, please provide your guest's name.
Do you have any special needs to assist you in attending the class?
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Yes
No
If YES, please describe your needs and how we can best meet them.
By checking this box, you agree that you have read and understand the statement below.
*
I understand that filling out this form does not guarantee me a spot in any specific Parent Education Class. If the organization is able to accommodate my request, I will receive an email confirming that I am registered for the desired class. If the requested class is not available, I will be provided with alternative classes by phone or email.