Family Wellness Roanoke Parenting Workshop Registration Form

Please fill out this form, and we will reach back out to you.
Parent Workshop Registration Form

Family Wellness Roanoke is supported by Blue Ridge Behavioral Healthcare, Prevention and Wellness Services, which provides a variety of evidence based programs that are designed to strengthen families by promoting positive family interactions and resiliency. We utilize evidence-based curriculum from the Make Parenting a Pleasure Program that covers ages 0-12 years of age, and these 4 week workshops are offered via Zoom.
Date
Parents receiving services through Roanoke City Department of Social Services:

Please note that if you are a parent/caregiver that has a caseworker with the Roanoke City Department of Social Services, you must NOT complete this form, and instead, have your caseworker submit a referral to clevasseur @brbh.org as soon as possible. Family Wellness Roanoke and the Roanoke City DSS have partnered to offer a more intensive program for you. Once Family Wellness Roanoke has received the referral, we will reach out to you.
Please fill out this form to register, and we will be in touch. If you have Gmail, please be certain to check your email inbox, Promotions folder and spam folder.
What language do you need?*

EnglishSpanish
Survey Question for future planning - Do you prefer to attend a virtual 4 week/once a week 1.5 hour session on:*

Weekdays 8am-9:30amWeekdays 6pm-7:30pmSaturday mornings 9am-10:30amAny of these options is fineNone of these - please feel free to write additional options in the comment section below
Name*

First NameLast Name
Email*
example@example.com
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
How old are your children?*
How did you find out about this parenting workshop series? Please state name of person or agency that referred you.*
Pick series dates*

Notify me via email and/or text message when registration opens for additional dates in 2025-no sessions are available in the summer months4 week series on Thursday mornings, October 3 thru October 24, 2024 from 8am-9:30am on Zoom.

Gender*

	Please select one of the following:
Male
Female
Gender Fluid
Non-Binary
Transgender
Gender-Neutral
Unknown
Prefer Not To Answer

Race*

	Please select one of the following:
White
Black
Asian
Native
Hawaiian
other/unknown
Multiple
Prefer Not To Answer

Ethnicity*

	Please select one of the following:
Non-Hispanic
Hispanic
Unknown
Prefer Not To Answer

Age*

	Please select one of the following:
18-20 years of age
21-24 years of age
25-44 years of age
45-64 years of age
65+ years of age
Prefer Not To Answer

I will do all home practice activities that are assigned each week.*

I agree
I will not use profanity or engage in other inappropriate behavior as this will not be allowed and reasonable attire is required. Family Wellness Roanoke staff reserve the right to permanently remove participants from the workshop for unacceptable behaviors.*

I agree
I will maintain confidentiality by not sharing information about the other parent participants and Blue Ridge Behavioral Healthcare facilitators with anyone outside of the workshop. Family Wellness Roanoke staff reserve the right to permanently remove participants from the workshop for violating this policy. Participants may NOT be out in public or at work during workshop sessions.*

I agree
I understand that I will not receive a certificate of participation if I do not meet the minimum attendance and participation requirements as will be explained in session 1 by the facilitators.*

I agree
If you are a parent or caregiver that is receiving services through a court of another Social Services Agency OTHER THAN Roanoke City, Blue Ridge Behavioral Healthcare/Family Wellness Roanoke can provide these agency workers with:*Confirmation of parent workshop enrollment; *Attendance record; *A copy of any parenting workshop certificate of completion (if one has been earned). This information will only be supplied to the requesting agency once we receive a signed release/exchange of information consent form signed by you from your caseworker. This signed release/exchange of information form can be faxed to Cindy Levasseur at Fax: 540-266-7016 or via secure email to: clevasseur@brbh.org*

I will contact my caseworker and ask them to send a signed release of information form to Cindy Levasseur within 2 weeks of this form submission.I decline
I understand and agree to this participation agreement in it's entirety. Since this form is provided by email prior to the first session, my being present at any and all parenting workshop sessions that I registered for serves as further proof that I agree to these terms.*

I agreeI decline (this option will result in your removal from the parenting workshop)
Comments?
Should be Empty:

Parent Workshop Registration Form