EPIC Parenting Class Registration
Fill out the form carefully for registration
Parent Name
*
First Name
Middle Name
Last Name
Parent Birth Date
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
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5
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31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
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1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Gender
*
Please Select
Male
Female
N/A
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County
*
Jefferson
Shelby
E-mail
*
example@example.com
Phone Number
*
I am a
*
Please Select
Mother
Father
Caregiver
Legal Guardian
Other
Children's Ages (Type your response here, separate the ages of multiple children with a comma)
*
Do you have a disability?
Yes
No
Do you have any barriers to participation?
*
Yes
No
If yes, please describe your barriers to participation.
What is your preferred class location?
*
Jefferson County Family Resource Center
Children's Aid Society of Alabama (Birmingham)
What is your preferred class time?
*
Morning
Afternoon
Evening
How did you learn about EPIC parenting?
*
Self-referred
Friend/Family Member
Professional
Court
DHR
Social Media
Other
Submit
Should be Empty: