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Program Registration Form

Fill out this for to register for The Mothers and Children Living Peaceful Lives program. To find out more about this program or other offerings from us please visit the Groups page.

Parent Information

Custodial Parent *

Custodial Parent's Date of Birth *

Address *

City *

Telephone *

Email Address *

Child Information

Child's Name *

Child's Date of Birth *

Gender Child Identifies with*:

Child's School

Grade

Educational or Special Learning Needs

Accommodations required related to a disability?

If yes please provide more details

Siblings

Name

Date of Birth

Name

Date of Birth

Name

Date of Birth

Name

Date of Birth

Secondary Contact for Family

Name

Phone Number

Address

City

Referral Source

Name of Worker

Phone Number

Agency Name

Other Agencies Involved with Family

Personal Saftey for Mother and Child:

Brief Family History and Any Relevant Information

Indicate Current Family Issues (custody/access, child behavior, any other relevant information)

Consent to Release Information:

I consent to the release of information for the purpose of my child participating in the Community Group Program: Mothers and Children Living Peaceful Lives, between the referral agency and Women’s Community House. The consent is only valid while the child is receiving services of the program.

Agree

All areas with marked with an * are required