Parenting Workshop Registration Form

Parenting Workshop Registration Form
Parent Full Name*

First NameLast Name
Birth Date*

MonthDayYear
Gender*

FemaleMaleOther/Prefer not to answer
E-mail*
Phone Number*

Area CodePhone Number
Zip Code*
County of Residence:*
(Must reside in Fulton County to receive diapers)
Ethnicity:*

Black or African-AmericanCaucasianMulti-racialHispanic or LatinoAmerican Indian or AlaskanAsian or Pacific IslanderOther
Current Living Arrangements:*

At Home with Parents(s)Living Alone (Rent/Own)Living with RoommateLiving with Significant Other or SpouseShelters/Transitional Housing/HotelCar/StreetOther
Current Employment Status:*

Full-TimePart-TimeUnemployedOther
Annual Household Income:*

Less than $20,000Less than $50,000Less than $75,000Less than $100,000More than $100.000
Do you receive any of the following benefits?*

Food stamps/EBT/SNAPTANFWICMedicaidPeachcare for KidsCareSourceWellcareMedicareNo
Number of members living in household:*
Adults and children including yourself
Are you currently Pregnant?:*

YesNoNot sure
If you are pregnant, when is your expected due date?:

MonthDayYear
Date
Are you interested in receiving counseling services for yourself or a family member? If so, someone from Integrated Counseling Center will reach out to provide additional information?:*

YesNo
Do you have reliable transportation options avaliable to you?*

YesNo
Signature: To confirm that all the information provided in this application is true to the best of my knowledge. I understand the Program Attendance Policy and agree to commit to attending all workshops. I acknowledge that only one emergency absence is allowed. If accepted into the program, I can commit to these requirements and will serve as an active participant. I understand that if I miss the maximum number of program sessions, I may be removed from the program and/or forfeit part or all of the allotted program giveaways. I also release Blessings Working Together and Integrated Counseling Center the right to use my name, photograph, and other information transmitted during the course of my program involvement, with the exception of any sensitive financial or personal information, for the purpose of program outreach, recognition, and performance measurement. I agree to the terms and conditions stated above.*

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