1242 Market Street, 2nd Floor, San Francisco, CA 94102-4802
Phone: (415) 437-0700 or (800) 392-9239 Fax: (415) 437-0796 Email: kidsturn@earthlink.net
www.kidsturn.org
This form is to be completed by parents to register themselves for Kids? Turn. EACH PARENT MUST FILL OUT HER OR HIS 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 you 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. This form will not register your child(ren)?s other parent for his/her workshop. Please print or type your information and return this form and child(ren)?s forms with your payment.
Payment MUST accompany registration to reserve a space in the workshop.
Your First Name: Last Name: Address: City: Home phone: Work phone: E-mail Address: Employer: Occupation: Ethnicity (Optional):
Home phone:
Work phone: E-mail Address:
Ethnicity (Optional):
Workshop for which you are applying
Date: City:
How were you referred to Kids' Turn? (Circle one or more and fill in additional information where appropriate.)
Attorney/Therapist
Pediatrician
Friend/Family
Other
Family Court Services/Judge
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Name of other parent:
Name First: Last Name Address: City: Zip Code Employer: Occupation: Home phone: Work phone: Ethnicity (Optional):
Work phone:
Would you be willing to attend the same session as your child(ren)?s other parent? Yes No
[In some cases, Kids' Turn may request that you attend different sessions.]
Name of your child(ren) who are 0-4 years old: Name/ages of your children 4-17 years old:
Have you attended Kids' Turn for children 4-17 years old? Yes No
If yes, list date, location, names of children who attended
Length of marriage or cohabitation with this child?s other parent:
Date of separation? [If not yet separated, state when you plan to separate] Month Year
Is there currently any litigation concerning child custody or visitation? Yes No
If yes, please explain:
Has your family been involved with Child Protective Services: Yes No
Restraining Order? Current Past None
How have you been affected by this separation or divorce?
What do you hope to get out of attending this workshop?
Does your child?s other parent have information about the workshop? Yes No
Child?s Name: Gender: Boy Girl
Child?s Age: Date of Birth:
Who typically cares for your child during the day?
Day care/Preschool (Name)
Friend/Relative Other
Parent(s)
Approximately what amount of time does your child spend with each parent?
with you with other parent
Ethnicity (Optional)
Name(s) and age(s) of brother(s) and /or sister(s):
What are your observations of your child?s reactions to this separation or divorce?
What most concerns you about your child at this time?
Please circle the response that most closely indicates the extent to which you agree or disagree.
1. I have a good understanding of my child(ren)?s reactions to the separation.
Strongly Agree Agree Neutral Disagree Strongly Disagree
2. I feel confident about my ability to help my child cope with my separation/divorce
3. My child?s behavior has changed for the worse since the separation or divorce.
4. Communication with my child?s other parent is difficult.
5. It is difficult for my child to adjust when going from one parent?s home to the other.
PARENT?S QUESTIONNAIRE
Please assist us in understanding more about your family?s situation. We will later pair this information with an evaluation form to understand what you have gained from attending Kids' Turn. This information will remain confidential.
1. I have a good understanding of my child(ren)?s reactions to the separation/divorce.
2. I have open and effective communication with my child.
3. My child talks to me about his/her feelings, questions, and concerns regarding the separation/divorce
4. I generally know how to respond when my child asks me difficult questions about the divorce or expresses his/her feelings about the divorce.
5. Communication with my child?s other parent is difficult.