Welcome | Family Registration

If you are looking to register for the upcoming Empowered to Parent training, you are in the right place. Space is limited in order to create the most effective learning environment.

Dates: Jun 2, 2022 - Jul 21, 2022

Time: 6p-7:30p

Cost: $175 (includes registration for 2 adult caregivers)

**$100 due at application; $75 due by May 19, 2022. Registration will be complete once payment is received.

Parent 1

First Name

Last Name

Phone

Primary Contact Number

(###)

###

####

Date of Brith

YYYY

Email Address

Mailing Address

City, State, Zip

Marital Status

Parent 2

ONLY INCLUDE IF PARENT 2 WILL BE ATTENDING TRAINING.

First Name

Last Name

Phone 2

(###)

###

####

Date of Birth

YYYY

Email 2

Foster Parents

Are you currently licensed or in process to foster?

Yes

Adoptive Parents

Are you an adoptive parent or in the process of adopting?

Yes

Child Information:

Please list information for children birth to 18 years old.

Child 1

First Name

Last Name

Age

Gender

Meet my child.

In order to best meet the needs of participants, list below mental health diagnosis, physical limitations, and/or known challenges your child may experience.

Child 2

First Name

Last Name

Age (Child 2):

Gender

Meet my child...

In order to best meet the needs of participants, list below mental health diagnosis, physical limitations, and/or known challenges your child may experience.

Do you have additional children to add?

For additional family members, please add information below: