Registration Form

(form revised 12/10)

To register for a Cooperative Parenting workshop, call 760-436-3039 and leave your name, your phone number and the workshop number you wish to attend. A confirmation letter will be sent to you.  Please complete this form & bring it to your first class.

                                                                                                                        Date_____________

Your name____________________________  e-mail__________________________

Your employment______________________________________________________

                                                (Title)                                                   (Company)

Home Address________________________________________________________

                                    (street)                                                                                 (city)                                     (zip code)

Your tel_________________________    ___________________________________

                                    (daytime)                                                            (evening)

Other parent name_______________________________________________________

Other parent address _____________________________________________________

                                                (street)                                                                 (city)                                     (zip code)

Other parent telephone____________________________________________________

Your Tuition (effective 1/1/2011) $________ (please fill this in)

*You may requested to show verification for income less than $30,000 a year.  Payment can be made by cash, check or credit card (Visa and Master Card only).  Payment can be made in three payments (at each session) if this is convenient for you unless you are paying with a credit card.  Credit and debit card charges are processed once for the full amount.

Guest Tuition:  Parents are encouraged to bring a guest (new partner or relative)  to Cooperative Parenting.  A guest who wants to receive a graduation certificate pays 50% of the tuition  paid by their partner.  If no certificate is desired, the guest attends for no charge. 

 If you are paying by check, please make it payable to:  “Shari Delisle”