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2. *ALL FIELDS MUST BE COMPLETED IN ORDER FOR US TO ACCEPT AND PROCESS YOUR REGISTRATION.

   Note: ACTIVE PARENTING:  The cost for the 6-week Active Parenting Classes (5 to 12 years old) is $25.  The cost for the 4-week Active Parenting Classes (0-5 years old) is $18.  The cost for Active Parenting Classes for Teenagers (13-18) is $18.  This Registration along with the exact fees for materials needs to be submitted at least one (1) week prior to the first start date of each class in order for you to be confirmed. See "Parenting Class Schedule" on our Parenting Class main page for schedule details.

   COOPERATIVE COPARENTING CLASSES: The cost for the materials for the 8-session classes (3-hours per session) is $25.00  See "Cooperative Coparenting Schedule" on our Parenting Class main page for schedule details.

4. Date: *
   Date:
6. FIRST NAME *
7. LAST NAME *
9. MAIDEN NAME (if different)
11. STREET NAME & NUMBER *
12. APT #
14. CITY *
15. STATE *
16. ZIP CODE *
18. PHONE: *
19. SECONDARY PHONE:
21. E-MAIL ADDRESS: *
22. BIRTH DATE: *
24. AGE / NAME OF CHILD OR CHILDREN: *
26. WHICH CLASS WOULD YOU LIKE TO PARTICIPATE IN? *

    1. Active Parenting (ages 5 to 12)
    2. Active Parenting (birth to 5)
    3. Active Parenting Teenagers (13-18)
    4. Cooperative Coparenting Class
27. HOW DO YOU PREFER TO PARTICIPATE?*

    1. In Person
    2. Via Zoom Class
29. WHAT DO YOU HOPE TO GET OUT OF THIS PROGRAM? *
31. QUESTIONS OR COMMENTS:
Leave This Blank:


33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit Submit and Print

* indicates a required field