Cultivate Connection Registration Form

Cultivate Connection Registration Form
Cultivate Connection, is a 9 week parent training. Classes meet on Tuesdays from 5:30 to 7:30 pm, at First Naz Church (First Church of the Nazarene), 1700 8th Street, Lewiston. We recommend that both parents/caregivers in the home attend. Childcare & child snacks are provided.

You will be required to purchase an E-Book for $49 per family, from Empowered to Connect (instructions provided later in this form).

In addition to the E-Book, you can also purchase a printed book for $69 or both E-Book and printed book for $109 (optional)

The next class begins September 10, 2024. Please complete all information below. A class facilitator will touch base with you prior to the class.

Class Facilitators: Jay & Angie Derting:

Contact:

angie.derting@gmail.com

509-552-9561

Please note - Space in this class is limited. Once the class is full, you will be placed on a waiting list for the next class. The facilitator will contact you to confirm whether you are in the class or wish to be placed on the waiting list.
Caregiver 1*

First NameLast Name
Address Caregiver 1*

Street Address

Street Address Line 2

CityState

Zip Code
Caregiver 2

First NameLast Name
Address Caregiver 2

Street Address

Street Address Line 2

CityState

Zip Code
Caregiver 1 Email*
example@example.com
Caregiver 2 Email
example@example.com
Caregiver 1 Phone*
Please enter a valid phone number.
Emergency Contact Number for Caregiver 1 (in the event of an emergency during class)*
Please enter a valid phone number.
Caregiver 2 Phone
Please enter a valid phone number.
Emergency Contact Number for Caregiver 2 (in the event of an emergency during class)
Please enter a valid phone number.
What are the first names and ages of the children in your care? Please indicate if the child is biological, foster, foster-adopt or private-adopt. (This is confidential.)*
Childcare & snacks will be provided for your children, ages NB to 12 years. Please let us know of any food allergies or other issues we need to be aware of*
What is a parenting issue you would like us to address?
What is something you hope to learn from this training?
Each Caregiver will attend all meetings. (Choose one)

Both can attend the scheduled classesOnly one of us can attend the scheduled classes
Release of Liability/Hold Harmless and Confidentiality Agreement

Each participant is required to read and sign below to enroll in the class
Release of Liability/Hold Harmless Agreement

By signing below, you agree to RELEASE FROM LIABILITY AND HOLD HARMLESS Homes of Hope, a registered Non-Profit located at 818 17th Ave, Lewiston, ID 83501, including its employees, volunteers, board of directors and officers, from all claims, liability, negligence, damages, judgments, medical payments or demands for monetary relief of any kind in connection with your attendance or your children’s childcare related to your attendance of this class or activity, including any activities which may result in injury, harm, or other damages.

Class Agreement

I agree to meet for 9 sessions in the class, Cultivate Connection. I will make my best effort to attend each meeting, understanding that my absence affects not only my learning and growth but the entire group. If I am going to be absent, I will notify the facilitator, Angie Derting. Email: angie.derting@gmail.com or phone: 509-552-9561.

I agree to receive communication via text from Angie or Jay specific to this training class.

I agree to participate appropriately during exercises and discussions. I will be authentic with others, focus on my family goals and put what I learn into practice at home. I understand I am not required to share anything I am not comfortable talking about.

I agree to keep all personal information and experiences that are shared in the class confidential. I will not talk about what is shared in the class outside of the class.

I understand that the facilitators, Jay and Angie Derting, are mandatory reporters. Mandatory reporters are required to report the facts and circumstances that led them to suspect that a child has been abused or neglected.
Caregiver 1*

Clear
Caregiver 2

Clear
How to Purchase Your Class Book
Once you submit this form you will receive an email giving you the Empowered to Connect website link, which you will need later on to purchase your E-Book Participant Guide, which is a requirement for the class.

The facilitator, Angie Derting will then contact you to chat about the class and give you an access code so you can purchase your E-Book via the Empowered to Connect website link.

You only need to purchase one Participant Guide per family.

Required - Downloadable E-Book - $49

Optional - Printed book - $69 or E-book and printed book - $109

*Financial Hardship - If you would like to attend the class but are unable to purchase the book, please contact our office to discuss. We may have limited funds available to assist.

Our Office Phone Number is 208-413-6770

Email: admin@homesofhopeidwa.org
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Cultivate Connection Registration Form

Release of Liability/Hold Harmless and Confidentiality Agreement

How to Purchase Your Class Book