Healthy Parenting: Parent Education Program

First Name of Program Participant *
Last Name of Program Participant *
Address *
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Email *
E news sign up
By checking the box below, I agree to subscribe to DRC e-news which will be sent to email provided. I understand that I may unsubscribe at any time. DRC does not exchange, rent or sell its mailing list to any outside organization.Yes! I want to receive DRC e-news!
Daytime Phone *
Evening Phone/Cell *
Child's name/age/gender
Child's name/age/gender
Child's name/age/gender
Child's name/age/gender
Children live primarily with:
Referral Source: Healthy Parenting Program Fee is $300 for 30 hours/ten weeks.
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; (D) $15 rescheduling fee will apply for each date change; (E) 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. I certify that the credit card used for payment is in my name as Program Participant and I authorize payment to DRC as submitted through PayPal for this class. *Signature - type name in box