Name* First Last Email* Docket #* If you do not know the Docket# when registering, enter Unknown. Please note, you will need to have the Docket# in order to receive certification that you completed the program. Name of Court Co-Parent Name Mailing AddressAddress Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is a restraining order in effect in this case? Yes No Co-parents will be placed in separate classes unless indicated I prefer to attend the same seminar as my co-parent I prefer not to attend the same seminar as my co-parent Day Time Phone Number Do you need a Foreign Language Interpreter? Yes No If yes, please list language. Do you need a Sign Language Interpreter? Yes No Seminar Sessions** Due to COVID-19, seminars are being held virtually. You will receive a link to the Seminar upon confirmation.** The seminar consists of two 2-hour sessions. You must attend both sessions Please indicate several choices numbered by preference. If the seminars you have selected are unavailable, you will be placed in the next open class *Please note that your placement in a particular seminar is not guaranteed until it is confirmed by this office. First Choice Thursdays November 14th and 21st 6:00 PM to 8:00 PM Mondays December 2nd and 9th 6:00 PM to 8:00 PM Thursdays December 12th & 19th 6 to 8 pm Second Choice Thursdays November 14th and 21st 6:00 PM to 8:00 PM Mondays December 2nd and 9th 6:00 PM to 8:00 PM Thursdays December 12th & 19th 6 to 8 pm Third Choice Thursdays November 14th and 21st 6:00 PM to 8:00 PM Mondays December 2nd and 9th 6:00 PM to 8:00 PM Thursdays December 12th & 19th 6 to 8 pm A $25.00 rescheduling fee will be charged for missed classes. Failure to complete the seminar within six months of your initial registration will require payment in full. Cost per person: $85.00 payment accepted by check, money order, Visa, Mastercard or Discover credit card. Registration in seminar will not be confirmed until payment is received. Please make checks and money orders payable to Riverbend CMHC. If you receive State and/or Federal assistance, or believe your circumstances meet eligibility for a reduced fee, contact your designated Court to complete a financial affidavit. Court approved waivers must be submitted prior to registering for the Child Impact program.Child Impact Program Registration Fee Quantity Price: $85.00 Quantity For "Quantity', please enter the number of people you are paying for. If you are paying for your co-parent, please have them submit their own registration form.Total $0.00 Billing Address (required)Billing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Credit Card*Card Details Cardholder Name Δ