Parents Apart Virtual Class Registration Form

"*" indicates required fields

Name*

First Last

Address*

Street Address City State ZIP Code

Phone Number*

Email*

Enter Email Confirm Email

Name of Co-Parent*

First Last

Child's Name/Age/Gender*

Referral Source*

Judge - specify below

Self - Referred

Attorney

Other

If Court-referred, please enter the name of the judge, the courthouse, and the Family File or Docket #. All three items are required if court-referred.

Select First Choice of Dates*

Select Second Choice of Dates

All classes are held from 7:00 pm to 9:30 pm.

E-news sign up

Yes! I want to receive DRC e-news!

By checking the box above, I agree to subscribe to DRC e-news which will be sent to my email address above. I understand that I may choose to unsubscribe at any time. DRC does not exchange, rent or sell its mailing list to any outside organization.

Parents Apart Classes

Price:

Fee is for total of both classes.

Payment Method

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

TERMS OF REGISTRATION: (A) an email will be sent to address provided with registration confirmation and instructions for attending class; (B) No reminders provided prior to class start date; (C) Notification required 48 hrs prior to date of first class if unable to attend; $15 rescheduling fee will apply for each date change; (D) Failure to attend scheduled class forfeits any money paid.*

I have read, understand and agree to above terms by typing my name in signature box below.

Signature - Type name in box*

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Parents Apart Virtual Class Registration Form

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