Intentional Parenting Registration Form
Children Name(s) and Date of Birth (MM/DD/YYYY)
Parent's Name
*
Name
Date of Birth (DD/MM/YYYY)
Additional Parents or Caregivers planning to attend the Intentional Parenting
Parental Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Are you or your child engaged in counseling or peer coaching services with Collaborative Trauma Solutions?
Yes
No
Not yet, I would like someone to contact me about services
Do you or your child have Medicaid?
Yes
No
Not sure/ I don't know
If so, provide Parent and/or Youth Legal Name and Medicaid Number
How did you find out about or were referred to this program?
*
Please check the upcoming Intentional Parenting Workshop I would like to attend:
*
Saturday
Thursday December 5th 8:30a-12:30p @ 543 S. Street, Montrose CO 81413/Virtual
How do you plan to attend?
*
In person
Virtually
We strive to provide tools and lenses to meet your parenting needs. Please share any information that feels relevant to parenting challenges or focuses you desire to gain additional knowledge and tools in.
We drive to meet the needs of our Montrose Community, please provide other topic ideas or areas would be beneficial to building stronger relationships in your family.
Private Pay
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USD
$350 per person full cost, $175 deposit amount if unable to pay in full. Full payment due prior to workshop.
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
Google Pay
After submitting the form, you will be redirected to Google Pay to complete the payment.
Please sign after reading the acknowledgement above
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