EARLY YEARS PARENT WORKSHOP REGISTRATION FORM
1242 Market Street, 2nd Floor, San Francisco, CA 94102-4802
Phone: (415) 437-0700 or 1-800-392-9239 Fax: (415) 437-0796
This form is to be completed by parents to register themselves for Kids' Turn. EACH PARENT MUST FILL OUT HIS OR HER OWN REGISTRATION FORM(S). In addition, please complete one child's registration form for each of your children. We will not sign up your child's other parent for your workshop but we do encourage the other parent to attend a similar program beginning on a separate date. Each parent who registers should complete a separate child's registration form for each child. In the event your child's other parent does not have copies of this registration form please provide one for him or her, or request that one be sent to him or to her. This form will not register your child(ren)'s other parent for his/her workshop.PLEASE PRINT OUT THIS FORM, PRINT OR TYPE your information and return this form and the child(ren)'s forms to Kids' Turn at the above address with a signed consent form and your payment.
1. YOU
Your Name: ___________________Occupation:______________
Employer:_________________
Address: ____________________________ Home
phone: ( )
____________________
City/Zip:____________________________
Work phone: ( )
_____________________
Ethnicity (optional) ______________________________ E-mail address:
__________________________
2. OTHER PARENT: (THIS DOES NOT MEAN
THAT HE OR SHE IS REGISTERED)
Name:_____________________________Occupation:________________________________
Address: ___________________________ Home
phone: ( )
_______________________
City/Zip: __________________________ Work phone:
( ) _______________________
Ethnicity (optional)___________________________
3. WORKSHOP FOR WHICH YOU ARE APPLYING:
DATE :_______CITY: _____________
4. How were you referred to KIDS' TURN?
(Circle one or more and fill in additional information where appropriate)
Attorney/Therapist ______________(name?) Friend/Family
Other
(Identify)_______________________ Family Court Services/Judge
(city?)___________________
Ad (where?)
___________________________________
5. Have you attended Kids' Turn for children
4-17 years old? ______Yes ____No
If yes, list date,
location, and names of your children who attended:
6. Name(s) of your child(ren) who are 0-3
years old:
7. Name(s) of your children who are 4-17 years
old:
8. How many years did you and your child's
other parent live together?
9. What is the approximate date you and your
child(ren)'s other parent stopped living together? ___________
If not yet separated,
state when you plan to separate:________________
10. Is there currently any litigation
concerning child custody or visitation? ____Yes ____No
If yes, please explain:
11. Has your family been involved with Child
Protective Services? ____Yes ___No
If yes, please
explain:
12. Restraining Order?
_____Current _____Past _____None
(Parents with a current restraining order should attend
separate workshops, unless the restraining order allows for peaceful contact for
the purposes of dealing with custodial arrangements, or unless the restraining
order can safely be altered to permit attendance at Kids' Turn.)
13. How have you been affected by this
separation or divorce?
14. What do you hope to get out of attending the parents' workshop?
15. Does your child's other parent have information about the workshop? __Yes ____No