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.
Please leave this field empty.
Custodial Parent *
Custodial Parent's Date of Birth *
Email Address *
Child's Name *
Child's Date of Birth *
Gender Child Identifies with*:
Educational or Special Learning Needs
Accommodations required related to a disability?
If yes please provide more details
Date of Birth
Name of Worker
Other Agencies Involved with Family
Personal Saftey for Mother and Child:
Low RiskModerate RiskHigh Risk
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.
All areas with marked with an * are required