Date:
PARENTS APART® Confidential Registrationtion Registrtiontion
PARENTS APART®
Date:
Theses 6 hour workshops are held once a month alternating between two Monday evenings from 6 - 9 pm and one Saturday from 9 am - 4 pm with a 1 hour break.
Confidential Registration Are you in danger of your partner or ex-partner doing any of the following:
Physically hurting you by pushing, grabbing, slapping, hitting, choking or kicking you?
Please number up to three dates in order of preference. (1 = first, 2 = second, etc
Threatening to hurt you or your children or someone close to you?
We will call you to confirm registration.
Stalking, checking up on you or following you?
Making you afraid?
2017 Parents Apart® workshops ____ January 9 & 23, Mondays
____YES (You will be contacted by the Parents Apart®
____ February 11, Saturday
Coordinator). Please indicate the safest way to contact
____ March 13 & 20, Mondays
you.__________________________________________
____ April 15, Saturday ——- May 8 & 15, Mondays
____NO (None of the above applies to me or I choose not
____ June 10, Saturday
to answer at this time.)
____ July 10 & 17, Mondays ____ August 12, Saturday
For help and support if you answered YES
____ September 11 & 18, Mondays
call the Advocacy Center, 607-277-5000 (24 hr)
____ October 14, Saturday
www.theadvocacycenter.org
——- November 6 & 13, Mondays ____ December 9, Saturday Name ________________________________________ Mailing Address_________________________________ ______________________________________________
Cost: $60—$100 program fee* payable to CCE-Tompkins
City _________________ State_____ Please indicate your choice of payment:
Zip Code ______________ Phone: (work) __________________________________ (home/cell) ____________________________________
___ check enclosed, amount ______________
Email: ________________________________________
___ pay when attending, amount ___________
Full name of other parent:
___ credit card (we’ll call you)
______________________________________________
___ request a reduced fee (we’ll call you)
Are you Court Ordered? ____ Yes
____ No
Docket #: ____________________ File #: ____________ # of Children___________ If not court ordered, referral source: ____________________________________________
*Program fees are based on a self-determined sliding scale. Amounts over $60 are used to provide scholarships for those in need, and represent a tax-deductible contribution to our program.
Fax: (607)272-7088
www.ccetompkins.org
PARENTS APART®
Date:
Theses 6 hour workshops are held once a month alternating between two Monday evenings from 6 - 9 pm and one Saturday from 9 am - 4 pm with a 1 hour break.
Confidential Registration Are you in danger of your partner or ex-partner doing any of the following:
Physically hurting you by pushing, grabbing, slapping, hitting, choking or kicking you?
Please number up to three dates in order of preference. (1 = first, 2 = second, etc
Threatening to hurt you or your children or someone close to you?
We will call you to confirm registration.
Stalking, checking up on you or following you?
Making you afraid?
2017 Parents Apart® workshops ____ January 9 & 23, Mondays
____YES (You will be contacted by the Parents Apart®
____ February 11, Saturday
Coordinator). Please indicate the safest way to contact
____ March 13 & 20, Mondays
you.__________________________________________
____ April 15, Saturday ——- May 8 & 15, Mondays
____NO (None of the above applies to me or I choose not
____ June 10, Saturday
to answer at this time.)
____ July 10 & 17, Mondays ____ August 12, Saturday
For help and support if you answered YES
____ September 11 & 18, Mondays
call the Advocacy Center, 607-277-5000 (24 hr)
____ October 14, Saturday
www.theadvocacycenter.org
——- November 6 & 13, Mondays ____ December 9, Saturday Name ________________________________________ Mailing Address_________________________________ ______________________________________________
Cost: $60—$100 program fee* payable to CCE-Tompkins
City _________________ State_____ Please indicate your choice of payment:
Zip Code ______________ Phone: (work) __________________________________ (home/cell) ____________________________________
___ check enclosed, amount ______________
Email: ________________________________________
___ pay when attending, amount ___________
Full name of other parent:
___ credit card (we’ll call you)
______________________________________________
___ request a reduced fee (we’ll call you)
Are you Court Ordered? ____ Yes
____ No
Docket #: ____________________ File #: ____________ # of Children___________ If not court ordered, referral source: ____________________________________________
*Program fees are based on a self-determined sliding scale. Amounts over $60 are used to provide scholarships for those in need, and represent a tax-deductible contribution to our program.
Fax: (607)272-7088
www.ccetompkins.org
