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Strengthening Families Program Registration
Sign up for an upcoming class cycle by providing your contact information.
Parent/Guardian Name
*
First Name
Last Name
Preferred Names
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact
*
Name
Relationship
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Please list all children participating in program
*
Rows
Name
Age
Grade
School
Special Considerations (allergies, learning needs, etc.)
Child 1
Child 2
Child 3
Child 4
Child 5
Program Session
Strengthening Families meets once weekly for 7 weeks. Session dates: October 14, 21, 28 and November 4, 9, 18 & 23 from 5:30 p.m. (dinner) to 8:00 p.m.
Meals & Accessibility Needs - Will your family participate in the provided meal?
Yes
No
Food Allergies or dietary restrictions
Accessibility needs (language, mobility, sensory, etc.)
Do you need transportation assistance?
*
Yes
No
If Yes: Please describe the assistance needed
Parent/Guardian Commitment - I commit to attending all sessions unless an emergency arises.
*
Yes
No
Media Release (Optional) I consent to photos of my family being used for Coalition Communications
Yes
No
Additional Notes or Questions
Parent/Guardian Signature
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Register
Should be Empty: