Please do not use all UPPER CASE or all lower case letters.   Why? Other cooperative parent must fill out a seperate registration to attend this course. Both parents' attendence is recommended but not required.
Required info in red	Parent	Current Spouse (only if registering to attend course with parent)
First (Given) Name
Last (Family) Name
Age
Special Needs (diet, med, etc)

Course Date	please select April 7, Rancho Cordova July 12, Roseville September 7, Sacramento November 3, Folsom	Cooperative Parenting and Divorce
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.

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