Parallel Parenting Class!

Cooperative Parenting Registration Form (form revised 12/09) 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 ______________________________________________________

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 1/1/2010) $________ (please fill this in)

*You are requested to show verification for income less than $20,000 a year to assure that tuition payments are accurate. Thank you for your willingness to provide verification if asked to do so. 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. Guest Tuition: Parents are encouraged to bring new partners or other guests 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 De