Parenting Class Registration

2. Class Location & Cost:

   Classes are held at the George L. Gordon, Jr., Government Center, Activity Room located at 1300 Courthouse Road, Stafford, VA 22554. <br><br><b>Fee:</b> $15-25 cash to purchase book for the session.<br><br> <b>Please note:</b> If you register for a class and you have a no-contact or protective order against another individual who may also need to take the class, you must alert me and provide the appropriate documentation.

   Classes are held at the George L. Gordon, Jr., Government Center, Activity Room located at 1300 Courthouse Road, Stafford, VA 22554.
   
   Fee: $15-25 cash to purchase book for the session.
   
   Please note: If you register for a class and you have a no-contact or protective order against another individual who may also need to take the class, you must alert me and provide the appropriate documentation.

4. First Name:*

5. Last Name:*

7. Spouse/Partner Name:

9. Address 1:*

11. Address 2:

13. City:

14. State:

15. Zip:

17. Phone:*

18. Work Phone:

19. Cell Phone:

21. Email:*

23. Ages of Child(ren):

25. What behavior issues are you having a difficult time managing?

27. Are you required to take a Parenting class? Are you involved with Court, Social Services, Probation etc?*

    1. Yes
    2. No

28. If Yes, please explain:

30. Registering for:*

    1. First Five Years (Class for parents of infants to 4 years of age)
    2. Basic Parenting (Class for parents of children 5-12 years of age)
    3. Active Parenting of Teens (Class for parents of pre-teens and teens)
    4. Families in Action (Teens are asked to attend with parents)

Leave This Blank:


31. 1. Receive an email copy of this form.
32. Email address

    This field is not part of the form submission.

33. Submit Submit and Print

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