Parenting Course Registration Form

Empowered Parenting Program: Part 1 Intake Form

Presented by Creating a Better Future Education Society
Select the cohort you want to join (British Columbia or Ontario)*
Parent / Caregiver Name #1*

First NameMiddle NameLast Name
Birth Date

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail*
example@example.com
Cell Number*

Relationship
What is your relationship status?*
If you are separated or divorced, what is the relationship like with your former partner?

Questions: Children
How many hours of screen time do the children have per day?*
Do the children participate in house maintenance and everyday chores? Please give examples. *
Describe the relationship between the children (if more than one). For example, are there many fights? Do they cooperate? Are they envious of each other? Do they play together?
Do your children have friends? How are the managing with their friends during Covid?
Do the children act and communicate with respect to their parents / caregivers?

Questions:
How much time do you spend with your children each day?*
What activities do you do with your children?*
Are the approaches the parents / caregivers take in educating the children different from each other?
What subjects cause tension at home? Please prioritize them.*
What are you hoping to learn in the course? What issues would you like to work on? What subjects would you like to have covered in the course? *

Participants' Agreement

Services: The services provided to the undersigned are for educational, experiential and informational purposes only, and are without guarantees of any kind.

Make-Ups: If you miss a class and wish to make it up, you may be provided with either a video or audio recording of the session.

Cancellations & Refunds: If you find that you need to withdraw from the course, you can be reimbursed for the classes you did not take, minus a $30 administration fee.

Photo & Video Release: Creating a Better Future Education Society reserves the right to use photographs and/or videos taken during courses or shared publicly on social media for purposes of instruction, advertising, marketing and promoting Creating a Better Future Education Society and its programs. If you do not wish to comply with this policy, please notify Creating a Better Future Education Society and teachers prior to participation.

Virtual Classes & Class Recordings: For privacy reasons, DO NOT share links to virtual classes or class recordings. We require all participants to register for the class on our website to receive a link to access the online content. When using an interactive platform, like Zoom, the video and audio from all participants will be recorded. While we usually try to only record the view of the "presenter", you are responsible for muting your own microphone and camera.

Click 'next' to agree to the terms and sign.

Agreement Signature

I, the undersigned, hereby agree on behalf of myself, my heirs, next of kin, legatees, executors, assigns, representatives, administrators, to release and forever discharge Creating a Better Future Education Society of and from, and waive any and all manner of actions, causes of actions, suits contracts, claims demands, losses, damages, costs, expenses, and all other legal obligations and compensation, of any kind, at any point in time, from or out of any service provided to the undersigned by Creating a Better Future Education Society. I covenant not to sue Creating a Better Future or any of their representatives, volunteers, directors, or employees, and further agree to indemnify, defend, and hold Creating a Better Future Education Society and any of their representatives, volunteers, directors, or employees harmless. The undersigned hereby approves that they have read, understood, and agreed to all of the terms and conditions stated in this document and that they agree that their signature also obliges and compels any representative or person acting on their behalf.
Signature*

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Empowered Parenting Program: Part 1 Intake Form