registration







To become part of one of our programs, please register with the following information.

Note: Your information will be kept in full confidence and used only for registration with the Family Center.

Name

Phone #

  E Mail

Street Address

City

State

Zip Code

Class/Program I would like to register for:

If you are taking this as a requirement for another program, to whom will the certificate of completion be given to?

About Your Children

How Many Children?

Ages of Children

Will they need child care?

($2.00 per child, per class/program)

Any special needs for children?

About You

Your Age

Sex

Ethnicity

Marital Status:

Completed College or Vo-Tech?

Degree or Diploma

Annual Family Income


(Used for grant writing purposes and needed if reduced fee is requested)