Please do not use all UPPER CASE or all lower case letters.   Why?
Required info in red	Parent	Parent
First (Given) Name
Last (Family) Name
Age
Special Needs (diet, med, etc)

Course Date	please select March 4, Rancho Cordova August 4, Sacramento November 16, Roseville Active Parenting for Stepfamilies
Mailing Address
City, ST Zip	,
Day Phone*	(Format: 530-555-1212)
Evening Phone
Email
Member of Kaiser? (not required to enroll)	No            Yes
Immediate Family Members*	Name Age Relationship Occupation or Grade (as appropriate)
* If you need more space, please use the comment section below to complete this section.
How did you hear about this class?	Doctor/Nurse Phone Message Flier Newspaper Friend Internet Search Engine Other please list:
Are you required to attend a parenting class?	No Yes, by whom?
Topics that you want to discuss in class.
Comment or additional information for the instructor.

(req) I understand my registration will be accepted only after you receive my payment and I receive my confirmation from Family and Community Educational Services. By pressing the send button below, I agree the terms and conditions.

Two ways to pay!   (please select) Online with Credit Card (or Debit Card). more info Mail a Check (to: FACES, 6905 San Angelo Court, Citrus Heights, CA  95621-4322)

(req) I have carefully rechecked the above information and it is correct.

Problems using this form?