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 ChoiceThursdays, November 14th & 21st, 6:00-8:00 pmMondays, December 2nd & 9th, 6:00-8:00 pmThursdays, December 12th & 19th, 6:00-8:00 pmSecond ChoiceThursdays, November 14th & 21st, 6:00-8:00 pmMondays, December 2nd & 9th, 6:00-8:00 pmThursdays, December 12th & 19th, 6:00-8:00 pmThird ChoiceThursdays, November 14th & 21st, 6:00-8:00 pmMondays, December 2nd & 9thth, 6:00-8:00 pmThursdays, December 12 & 19th, 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 Year20192020202120222023202420252026202720282029203020312032203320342035203620372038 Expiration Date Security Code Cardholder Name
