Families in Transition

Families in Transition Classes

Level I & Level II Class Registration Form
Registration
Legal Name*

First NameLast Name
Preferred Name

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
I agree to accept texts at this number:*

YesNo
Email*
Important: If you are taking this class via Zoom and do not supply an email address you cannot receive the link to attend!
What is your preferred form of contact?: *

Other Involved Parties
The Other Parent
Legal Name of the Other Parent*

First NameLast Name
Preferred Name

First NameLast Name
The Child(ren)
Click all age ranges that apply:*

Stage 1 – Birth to 18 Mos.Stage 2 – 18 Mos. to 3 Yrs.Stage 3 – 3 Yrs. to 5 Yrs.Stage 4 – 5 Yrs. to 8 Yrs.Stage 5 – 8 Yrs. to 12 Yrs.Stage 6 – 12 Yrs. to 16 Yrs.Stage 7 – 16 Yrs. to 19 Yrs.

About Your Situation
Is your case filed in court?*

YesNoNot Sure
County in which case is/will be filed:*
Case # CI-*
Your court case number will look like CI 21-0001. In this example, you would type 21-0001 above.
Have you been court ordered to participate in the parenting class?*

YesNoNot Sure
Parents are not allowed to take the class together when participation is court ordered. If you are not able to attend the month you are ordered, you may contact the court for permission to enroll in the next available class working around the date the other parent has been ordered to attend.
What is the class date assigned on your court order?: *

MonthDayYear
Date
Which class are you registering for?*

Level ILevel II
Select the class date you would like to register for:*

MonthDayYear
Date
Level II class is by appointment only, but please enter a few dates and times that work best for you and the office will contact you to coordinate scheduling according to the instructor's availability:*

Class Options
Class format?*

In-PersonZoom Livestream
Do you require an interpreter?*

YesNo, thank you
What language do you speak?
For Zoom Livestream, remember, you must be able to have your camera on and have microphone access to the entire 2 hours to receive credit for the course.
For Zoom Livestream, remember, you must be able to have your camera on and have microphone access to the entire 3 hours to receive credit for the course.
Level I Payment Options*

Payment - $46.35. (This will complete your registration.)Apply for fee waiver (You will need to fill out and upload the District Court's form below. Your registration for the class will not be complete until we receive the waiver signed by the judge in your case.)
Level II Payment Options*

Payment - $190.55 (This will complete your registration.)Apply for Reduced Fees & pay application fee - $66.95 (This will allow us to figure your fees using the sliding scale approved by the State Court Administrator's Office but your registration will not be complete until your final payment is made.)

Application for Waived Fees

for Families In Transition: Level I class
Once you complete the Judge's Waiver of Class Fees Application, uploaded it here with this application.
Attach Completed Application*

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Confirmation of inability to pay*

I hereby state that I am unable to pay the registration cost for the education program Families in Transition. I am applying to the Court for a waiver or reduction of that registration fee. The financial particulars that cause this inability are listed in the attached PDF. I understand that the fee waiver is not granted until approved by the court.
Acceptance of electronic signature*

I agree to utilization of an electronic signature. I agree the electronically stored copy of this form is enforceable to the same extent as if the documents and records were originally generated and maintained in printed form.
Electronic Signature*

Application for Reduced Fees

Mediation West offers a sliding fee scale based on your household size and income. You will need to provide income verification for each adult counted in your household size to pass audit requirements.
Number of adults living in your household for which you can provide income verification: *
Number of Children living in your household:*
Current household gross annual income (before taxes/deductions): *
Income verification must be provided for each adult used to figure household size. Please indicate which item(s) you are uploading:*

Your last two pay stubsThe first two pages of your last-filed tax returnGovernment benefits statement showing household income or benefitCourt order declaring you "in forma pauperis"Verification of incarceration
File Upload*

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I agree to the following:*

With my electronic signature, I certify that as of today’s date, my gross household income and the number of people living in my household are as I have indicated above. I understand that this information will be used in determining my eligibility for participation in the reduced fee grant program which utilizes federal and state funds; falsification of claims made on this application may subject the reporting party to federal or state penalties.
Acceptance of electronic signature*

I agree to utilization of an electronic signature. I agree the electronically stored copy of this form is enforceable to the same extent as if the documents and records were originally generated and maintained in printed form.
Electronic Signature*

Finalize Class Registration
You are registering for the {whichClass} class on {whatIs19}{selectThe}

Payment of ${levelI}{levelIi} is due today.
Subtotal
Payment Amount

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Payment Methods

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Families in Transition Classes

Registration

Other Involved Parties

The Other Parent

The Child(ren)

About Your Situation

Class Options

Application for Waived Fees

Application for Reduced Fees

Finalize Class Registration