Fatherhood Development Workshop / Strong Fathers Class Registration

Today's Date

Date

Are you completing this Online or at Orientation?*

At Home OnlineAt Orientation

Class Number*

What class are you enrolling in?

Full Name*

First NameMiddle NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

E-mail*

Social Security Number*

Date of Birth*

MonthDayYear

What is your current age?*

Phone Number*

Are you currently on

Officers Name*

First NameLast Name

Officers Email*

example@example.com

Officers Phone Number

Area CodePhone Number

If we cannot reach you, who can we contact?

Are you registered for Selective Service*

YesNo

Do you have a disability*

YesNo

Please enter you emergency contact name, phone number and relationship

Are you a Veteran*

YesNo

Employment*

Employer Name

Hourly Rate ($/hr)

Number of Hours per Week

Number of Days Employed (ex. 30, 60, 90, etc.)

If employed, list 1) Employer, 2) Hourly Rate 3) Number of Hours per week worked 4) Number of days employed

Are you looking for a job

Please estimate your annual Income*

Number of people in household that you are responsible for (i.e. Children, partner, spouse)*

Gender*

MaleFemaleOther

Race*

Ethnicity*

HispanicNon-Hispanic

Marital Status*

Are you a parent?*

YesNo

Are you a Father or Caregiver*

YesNo

Are you an expectant Father*

YesNo

Where you ever in Foster Care as a child?*

Due Date

Date

Pregnant Mother's Name

First NameLast Name

Are you a US Citizen*

YesNo

How many Children do you have?*

How many of your children are under 18*

Children's Information (Please list DOB as MM-DD-YYYY)

	Childs Name	Age	Date of Birth	Gender	Paternity Established
Child 1
Child 2
Child 3
Child 4

Are any of your children on TANF?*

YesNoUnknown

Are any of your children currently a part of an open or active DCS Case?*

YesNo

Housing: You are currently?*

Renting apt/homeLiving with family/friendsOwn a home/Buying a homeHomeless

Are you receiving any of the following*

Have you ever been Arrested?*

YesNo

Have you ever been In Jail?*

YesNo

Have you ever been In DOC/Prison?*

YesNo

How many times have you been in DOC/Prison?

How long were you incarcerated the 1st Time?*

How long were you incarcerated the 2nd Time?*

How long were you incarcerated the 3rd Time?*

What type of convictions do you have*

Where are you incarcerated*

Please enter the date of release

What is your release date?*

Would you like assistance looking for a job>

YesNo

Are you Head of Household?*

YesNo

How engaged are you with your children?*

Not at allVery LittleSomewhatVery Much

How much time do you spend with your child/children?*

Annual Household Income*

Education*

Last Grade Completed*

List Special Skills and Certifications

Do you feel safe in your current relationship?*

Is there a partner from a previous relationship who is making you feel unsafe now?

I would like more information on

After Clicking submit you will be directed to Indiana Career Explorer. Create an account and complete the Career Assessment*

CLICK HERE STATING THAT YOU UNDERSTANDCLICK HERE FOR MORE ASSISTANCE AND SOMEONE WILL CALL YOU TO HELP

We will call you to schedule a time for you to come in and meet with a specialist*

CLICK HERE STATING YOU UNDERSTANDCLICK HERE IF YOU DO NOT UNDERSTAND AND SOMONE WILL CALL YOU TO HELP

Can you pass a drug test

YesNo

Are you experiencing any of the following issues

Do you need Eye Glasses?*

YesNo

Are you currently receiving Mental Health Treatment or Counseling?*

YesNo

Have you received Mental Health Treatment or Counseling in the past?*

YesNoOther

Are you currently prescribed any medication*

YesNo

Are you currently taking any prescribed medication*

YesNo

Up to what age was your father present in the home when you were growing up?

When you were growing up, how involved was your father with you?

How would you describe the relationship with your father now

How engaged are you with your children*

Do you have an open DCS Case?*

YesNo

Do you have an open Criminal Case?*

YesNo

What are the charges for your open case. *

Have you been vaccinated for Covid 19

YesNo

COVID Impact (Last 6 Months)*

Laid Off/DisplacedStopped Seeking EmploymentUnable to Find EmploymentNot Affected

ARE YOU VACCINATED FOR COVID 19*

YesNo

After you click submit COMPLETE THE NEXT FORM COMPLETLY to complete the sign up process.

Option 1Option 2Option 3

Where did you hear About Fathers and Families Center*

Friend/Family Member's Name

First NameLast Name

Please upload a copy of your ID to complete enrollment

Browse Files

Have you complete Orientation*

YesNoAlumni

If you have not completed Orientation, please contact Ms. Rhonda at 317-921-5935 to enroll today.

Informed Consent for Text (SMS) Messaging

With your consent, Fathers and Families Center would like to send text (SMS) messages to the mobile number you have provided in our records.

By providing your informed consent where indicated, you acknowledge that you have understood the information below and agree to participate in our text (SMS) messaging service.

Purpose and Description: Fathers and Famililes Center’s text (SMS) messaging service is designed to provide you with helpful information, reminders, and notifications via text messages sent to your mobile phone. We may use text (SMS) messages to communicate with you for a variety of purposes, including:

announcements and reminders of upcoming events and appointments,
surveys and polls

Voluntary Participation: Participation in our text (SMS) messaging service is entirely voluntary. You have the right to refuse or withdraw your consent at any time.

We do not share or sell SMS opt-in, or phone numbers for the purpose of SMS.

Benefits and Risks: Benefits: The text (SMS) messaging service aims to keep you informed about Fathers and Families Center by providing an additional method of convenient and timely communication.

Risks: While every effort will be made to protect the security and confidentiality of information transmitted through text (SMS) messages, there are inherent risks associated with all electronic communication. These risks include unauthorized access, loss of privacy, and potential breach of sensitive information. It is important to be aware that text (SMS) messages may not be entirely secure and could be intercepted or accessed by unintended recipients.

Potential Costs: Participation in the text (SMS) messaging service may involve standard text messaging charges applied by your mobile service provider. Please consult your mobile service provider regarding any applicable fees or charges.

DID YOU READ THE Informed Consent for Text (SMS) Messaging*

YESNO

Click here to Opt in to Receive Txt messages or Opt out and not receive txt messages*

I am Opting in to receive Txt MessagesI am Opting OUT an do not want to receive txt messages

Click here to Opt in to Receive Phone Call or Opt out and not receive Phone Calls*

I am Opting in to receive Phone CallsI am Opting OUT an do not want to receive Phone Calls

Click here to Opt in to Receive Phone Call or Opt out and not receive Emails*

I am Opting in to receive EmailsI am Opting OUT an do not want to receive Emails

Attended Orientation:_9503

Program Name*

General Services

Class Number:_9506

Site Name*

Fathers and Families

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