9/30/2026 Triple P " The Power of Positive Parenting" Seminar
When: September 30, 2026 Time: 1:30- 3:00pm Where: Cognition Davie | 119 N. Salisbury Street, Mocksville 27028 What: Join Smart Smart of Davie County for a FREE parenting seminar! FREE childcare provided- children will be supervised in the upstairs play space while we meet. This seminar is best suited for families with children 5 and under.
Parent/Caregiver 1 Name:
*
First Name
Last Name
Parent/Caregiver 1 Email
*
example@example.com
Parent/Caregiver 1 Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Caregiver 1 Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Caregiver 1 Age Range:
*
Younger than 20
20-29
30-39
40-49
50-59
60-69
70 or Older
Prefer not to answer
Parent/Caregiver 1 Race/Ethnicity (select all that apply):
*
American Indian or Alaskan Native
Asian
Black
Hispanic/Latino
Middle Eastern/North African
Hawaiian or Pacific Islander
White
Prefer not to answer
Other
How did you learn about this program? (Select all that apply):
*
Word of mouth
Social media
Referral from Community Partner
Traditional Media
Outreach Event
Other
Do you want to register an additional parent?
*
Yes
No
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Parent/Caregiver 2 Name:
First Name
Last Name
Parent/Caregiver 2 Email
example@example.com
Parent/Caregiver 2 Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Caregiver 2 Address (only enter if different from Parent/Caregiver 1):
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Caregiver 2 Age Range:
Younger than 20
20-29
30-39
40-49
50-59
60-69
70 or Older
Prefer not to answer
Parent/Caregiver 2 Race/Ethnicity (select all that apply):
American Indian or Alaskan Native
Asian
Black
Hispanic/Latino
Middle Eastern/North African
Hawaiian or Pacific Islander
White
Prefer not to answer
Other
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Next
Child 1 Name:
First Name
Last Name
Child 1 Date of Birth:
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Month
-
Day
Year
Date
Child 1 Zip Code (if different from Parent/Caregiver):
Child 1 Age Range:
0-11 Months
12-23 Months (1 year)
24-35 Months (2 Years)
36-47 Months (3 Years)
48-59 Months (4 Years)
60-71 Months (5 Years)
72 or more Months (6 years or Older)
Child 1 Race/Ethnicity (select all that apply):
American Indian or Alaskan Native
Asian
Black
Hispanic/Latino
Middle Eastern/North African
Hawaiian or Pacific Islander
White
Prefer not to answer
Other
Will Child 1 be attending the class?
Yes
No
List any Allergies/Restrictions for Child 1:
Do you need to Register another Child?
Yes
No
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Next
Child 2 Name:
First Name
Last Name
Child 2 Date of Birth:
-
Month
-
Day
Year
Date
Child 2 Zip Code (if different from Parent/Caregiver):
Child 2 Age Range:
0-11 Months
12-23 Months (1 year)
24-35 Months (2 Years)
36-47 Months (3 Years)
48-59 Months (4 Years)
60-71 Months (5 Years)
72 or more Months (6 years or Older)
Child 2 Race/Ethnicity (select all that apply):
American Indian or Alaskan Native
Asian
Black
Hispanic/Latino
Middle Eastern/North African
Hawaiian or Pacific Islander
White
Prefer not to answer
Other
Will Child 2 be attending the class?
Yes
No
List any Allergies/Restrictions for Child 2:
Do you need to Register another Child?
Yes
No
Back
Next
Child 3 Name:
First Name
Last Name
Child 3 Date of Birth:
-
Month
-
Day
Year
Date
Child 3 Zip Code (if different from Parent/Caregiver):
Child 3 Age Range:
0-11 Months
12-23 Months (1 year)
24-35 Months (2 Years)
36-47 Months (3 Years)
48-59 Months (4 Years)
60-71 Months (5 Years)
72 or more Months (6 years or Older)
Child 3 Race/Ethnicity (select all that apply):
American Indian or Alaskan Native
Asian
Black
Hispanic/Latino
Middle Eastern/North African
Hawaiian or Pacific Islander
White
Prefer not to answer
Other
List any Allergies/Restrictions for Child 3:
Will Child 3 be attending the class?
Yes
No
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Next
Would you like to receive our Monthly Newsletter?
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PHOTO/MEDIA RELEASE
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I give consent to allow Smart Start of Davie County to photograph my child(ren) and/or me. I understand that these images may be used in the media, newsletter, or on Smart Start’s website.
I DO NOT give consent for my child(ren) and/or me to be photographed by Smart Start of Davie County.
Smart Start of Davie County loves to share success stories with our board, grantors/funders, and other relevant groups. If you share a story with us, are you willing for us to share it with these groups (no specific/identifying descriptors would be used in the sharing of your success story)?
*
YES, I give Smart Start of Davie County permission to share my success stories.
NO, I would prefer not to have success stories about me published at this time.
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