Strengthening Families Program Registration Form
Register your details to enroll.
Full Name
*
First Name
Last Name
Birth date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Are you an existing client of The Virtue Center?
*
Yes
No
How many of your children are ages 0-5 years old?
Please Select
0
1
2
3
4
5
Children under 6 years old will receive childcare during programming time.
How many of your children are ages 6-11 years old?
Please Select
0
1
2
3
4
5
Children between 6 and 11 years old will participate in group programming.
Please list the specific ages of each of your children.
Will your partner/spouse be attending program sessions as well?
Yes
No
I'm not sure yet.
Are you (and your partner/spouse, if applicable) available to commit to 15 weeks of group on Monday evenings beginning in September?
*
Yes
No
Questions or information you would like us to know:
Register
Should be Empty: