Registration Form for Parenting 101

Date

Name *

Address *

City: *

Zip: *

County: *

Phone number*

Email*

example@example.com

May we contact you? Select all that apply.*

Yes, you may contact me by phone.Yes, you may contact me by email.Yes, you may contact me by phone. Please use Caller ID to blockYes, you may contact me by mail.

Date of Birth *

Date

Age: *

Have you been here before?*

NoYes

If yes, when? *

How did you hear about us? *

Did you hear about us on:

FacebookInstagramwebsiteGoogle search

All of the programs and services listed here are provided FREE of charge to you by The LPC.

What is the primary services you are interested in? (please check one)

Parenting classIndividual CoachingMaterial Support ProgramAfter Abortion Support

Individual Coaching

Parenting Skills BuildingAdoption CounselingAfter Abortion Support

If applicable, are you currently pregnant?

YESNO

If YES, when is your due date?

type in your due date MM/DD/YYY

Please select the Parenting 101 session you wish to attend.*

FALLWINTERSPRING

Limitations of Services

The Laurel Pregnancy Center is a non-profit Christian organization. The staff and volunteers have received informal training in peer counseling and do not, for the most part, have degrees in counseling. The counseling provided is not, therefore, intended as a substitute for professional therapy. The LPC affirms a biblical worldview. It is the framework for our care and education. We do not expect or require anyone we serve to share a biblical worldview.

The LPC services include a non-profit medical pregnancy help clinic. Our medical services are provided by licensed medical professionals. They provide general pregnancy health education and information. They are not a substitute for dedicated prenatal care.

All pregnancy help services are provided free to anyone.

Our pregnancy help clinic offers information about abortion procedures and risks. This clinic does not provide abortion services or offer abortion referrals.

I have read and understood the above and hereby authorize the staff of this clinic to render whatever services are necessary for my care.

I hereby authorize and permit the Laurel Pregnancy Center to contact me.

Signature *

Parenting 101 Registration