Circle of Parenting Class Registration

For Ages 0-14 Months

August 29th - October 10th

Thursdays 11:00am to 12:15pm

7 Weeks $158

So that we can aggregate data for use in grant applications to receive funding for our programs and scholarships, we are asking for the following demographical information. Fields marked with a * are required fields.

Child Information

Child's Name

*

First Name

Last Name

Child's Date of Birth

*

(mm/dd/yyyy)

Child's Gender

Child's Ethnicity

Child's Disability Status

Primary Caregiver

Primary Caregiver's Name

*

First Name

Last Name

Primary Caregiver’s Relationship to Child

*

Email

*

Verify Email

*

Phone

Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Primary Caregiver's Birth Date

(mm/dd/yyyy)

Primary Caregiver’s Gender

Primary Caregiver's Ethnicity

Primary Caregiver’s Sexual Orientation

Primary Caregiver's Disability Status

Partner/Secondary Caregiver

Partner/Secondary Caregiver's Name

First Name

Last Name

Partner/Secondary Caregiver’s Relationship to Child

Partner/Secondary Caregiver's Birth Date

(mm/dd/yyyy)

Partner/Secondary Caregiver’s Gender

Partner/Secondary Caregiver’s Ethnicity

Partner/Secondary Caregiver’s Sexual Orientation

Partner/Secondary Caregiver’s Disability Status

Household Information

Are you requesting financial assistance?

Please select one of the options below and we will contact you to make a plan that works for your family.

Household Income

*

Household Income

Number of People in Household

*

Number of People in Household

What is the primary language spoken at home?

*

Photo Release

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

Will you please support Secure Beginnings 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

Other

Not at this time

Please describe how you'd like to support us

Payment

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.

*

$158 - Full Class Payment

$25 - Hold My Spot! I will complete payment the first week of class

$0 - Hold My Spot! Please contact me for scholarship or payment information

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