Welcome to Registration

Secure Beginnings Class Registration

January 7th - March 1st

Thank you for your interest in our programs!

If you have any questions or concerns, please do not hesitate to email us at programs@nantolbert.org or call (805)646-7559 x3.

Please select the class(es) below that you would like to register for:

If you are registering more than one child please complete a separate registration form for each child.

If the class you registered for is full you will be added to our waitlist, we will contact you to discuss other classes that might work for you and your family.

Please select the class you would like to register for:

Baby Floor Time at Monica Ros School - 12 to 24 months - Mondays 9:30am to 10:45am - $150

Toddler Play and Parent Education - 22 to 36 months - Tuesdays *Class is full. Complete registration to be added to waitlist*

Toddler Play and Parent Education - 22 to 36 months - Wednesdays *Class is full. Complete registration to be added to waitlist*

Circle of Parenting - 0 to 14 months - Thursdays 9:45am to 11:00am - $175

Your Child's Full Name

*

Child's Date of Birth

*

(mm/dd/yyyy)

Please note: We collect demographic information for Grant writing purposes and to understand the populations which we serve. Your name and information will never be shared.

You Identify Your Child's Ethnicity As

*

Please check all that apply.

African American/Black

American Indian

Asian

Caucasian

Hispanic/Latino

Mixteco

Pacific Islander

Blended or Mixed Ethnicity

TODDLER CLASS ONLY: Please list any dietary restrictions and allergies.

Emergency Contact (name, phone number and relationship)

*

Primary Caregiver and Household Information

Name

*

First Name

Last Name

Email

*

Verify Email

*

Phone

Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Your Relationship to the Child

*

Your Birthday

*

I Identify my Ethnicity As

*

Please check all that apply.

African American/Black

American Indian

Asian

Caucasian

Hispanic/Latino

Mixteco

Pacific Islander

Blended or Mixed Ethnicity

What is the primary language spoken at home?

*

Relationship Status

*

Married

I live with my partner, but am not married

I do not live with my partner and am not married

Single

Other

Partner's Name (if applicable)

First Name

Last Name

Annual Household Income

*

How many family members living in your household?

*

Intake Survey

Please rate the extent to which you agree or disagree with each of the following statements:

I believe I have all the skills necessary to be a good parent to my child.

*

Strongly Disagree

Somewhat Disagree

Disagree

Agree

Somewhat Agree

Strongly Agree

Being a parent makes me tense and anxious.

*

Strongly Disagree

Somewhat Disagree

Disagree

Agree

Somewhat Agree

Strongly Agree

I feel I have adequate social support.

*

Strongly Disagree

Somewhat Disagree

Disagree

Agree

Somewhat Agree

Strongly Agree

I need more support connecting to community resources.

*

Strongly Disagree

Disagree

Agree

Somewhat Agree

Strongly Agree

Please write down below anything else you would like us to know about you, your family or your child:

Please list any complications, surgeries, health issues, and traumas the child has experienced since he/she was conceived:

Photo Release

I grant to the Nan Tolbert Nurturing Center, its representatives and employees the right to take photographs and video of me and my child. I authorize NTNC, its assigns and transferees to copyright, use and publish the same in print and/or electronically.

How did you find out about The Nan Tolbert Nurturing Center

*

Friend/Family

Facebook

Internet Search

Professional: Doctor, Midwife, Counselor, etc.

Flyer

Other

Are you requesting financial assistance for this program?

All services are available on a sliding scale, based on your income, and we offer free introductions to our groups. Please check one of the boxes below and we will contact you to make a plan that works for your family. Our scholarship program follows the guidelines provided by Ventura County HUD http://www.ahacv.org/income_limits.shtml

Requesting scholarship

Requesting payment plan

Requesting scholarship and payment plan

Income Verification

Please upload a copy of your most recent tax return, W2, and/or 1099 form(s). If you are unable to upload, you can email to programs@nantolbert.org, or mail to P.O. Box 285 Ojai CA, 93024

Will you please support NTNC in one of the following ways? If so, please select the ways in which you will support the center.

*

Help assemble marketing materials (i.e. stuffing envelopes, folding forms)

Host a Fundraising Event (Annual Tea, Dinner Party)

Join a Committee (Programs, Fundraising, Marketing, Finance)

Business Sponsor or Offer Professional Services

Financial Donation

Not at this time

There is a $25 registration fee for all classes that will be applied directly to your class fee. Your registration is not complete until we have received your registration fee or your scholarship request has been confirmed. We will refund fees if needed.

*

$150 - Baby Floor Time at Monica Ros school

$240 - Toddler Play and Parent Education

$175 - Circle of Parenting

$25 - Hold My Spot! Please contact me for scholarship or payment plan information

Class Registration 2018/2019 Jan 7th to Mar 1st

Secure Beginnings Class Registration

January 7th - March 1st

Primary Caregiver and Household Information

Please rate the extent to which you agree or disagree with each of the following statements: