EPIC Registration Form (English)

EPIC Parenting Class Registration

Fill out the form carefully for registration
Parent Name*

First NameMiddle NameLast Name
Parent Birth Date*

MonthDayYear
Gender*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County*

JeffersonShelby
E-mail*
example@example.com
Phone Number*
I am a*
Children's Ages (Type your response here, separate the ages of multiple children with a comma)*
Do you have a disability?

YesNo
Do you have any barriers to participation?*

YesNo
If yes, please describe your barriers to participation.
What is your preferred class location?*

Jefferson County Family Resource CenterChildren's Aid Society of Alabama (Birmingham)
What is your preferred class time?*

MorningAfternoonEvening
How did you learn about EPIC parenting?*

Self-referredFriend/Family MemberProfessionalCourtDHRSocial MediaOther
Should be Empty:

EPIC Parenting Class Registration