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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