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 CourtCo-Parent NameMailing AddressAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is a restraining order in effect in this case?YesNoCo-parents will be placed in separate classes unless indicatedI prefer to attend the same seminar as my co-parentI prefer not to attend the same seminar as my co-parentDay Time Phone NumberDo you need a Foreign Language Interpreter?YesNoIf yes, please list language.Do you need a Sign Language Interpreter?YesNoSeminar SessionsThe 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 ChoiceMondays, January 6th & 13th, 6:00-8:00 pmThursdays, January 23rd & 30th, 6:00-8:00 pmMondays, February 3rd & 10th, 6:00-8:00 pmThursdays February 20th & 27th, 6:00-8:00 pmSecond ChoiceMondays, January 6th & 13th, 6:00-8:00 pmThursdays, January 23rd & 30th, 6:00-8:00 pmMondays, February 3rd & 10th, 6:00-8:00 pmThursdays, February 20th & 27th, 6:00-8:00 pmThird ChoiceMondays, January 6th & 13th, 6:00-8:00 pmThursdays, January 23rd & 30th, 6:00-8:00 pmMondays, February 3rd & 10th, 6:00-8:00 pmThursdays, February 20th & 27th, 6:00-8:00 pmA $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 are on State and/or Federal assistance, or cannot pay the full fee, please contact us at 226-7505 x4039.Child Impact Program Registration Fee 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 Credit Card American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20202021202220232024202520262027202820292030203120322033203420352036203720382039 Expiration Date Security Code Cardholder Name
