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Positive Discipline for Families Program Registration Form
Summer Series
July 19th – August 30th 2023
9:30 - 11:30 am Wednesdays
Facilitated in English through Zoom
↓
ADULT Participant (18+)
First Name:
Last Name:
Sex:
Female
Male
Sex/Gender:
Date of Birth:
Month/Day/Year
Date
January
February
March
April
May
June
July
August
September
October
November
December
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
Su
Sunday
Mo
Monday
Tu
Tuesday
We
Wednesday
Th
Thursday
Fr
Friday
Sa
Saturday
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
Our program will be providing you informational handouts during the class series. How would you prefer to receive them?
Please check your preference:
electronically by email
hard copy sent by mail
Address:
Address
City/Town
State/Province
AL Alabama
AK Alaska
AS American Samoa
AZ Arizona
AR Arkansas
CA California
CO Colorado
CT Connecticut
DE Delaware
DC District of Columbia
FM Federated States of Micronesia
FL Florida
GA Georgia
GU Guam
HI Hawaii
ID Idaho
IL Illinois
IN Indiana
IA Iowa
KS Kansas
KY Kentucky
LA Louisiana
ME Maine
MH Marshall Islands
MD Maryland
MA Massachusetts
MI Michigan
MN Minnesota
MS Mississippi
MO Missouri
MT Montana
NE Nebraska
NV Nevada
NH New Hampshire
NJ New Jersey
NM New Mexico
NY New York
NC North Carolina
ND North Dakota
MP Northern Mariana Islands
OH Ohio
OK Oklahoma
OR Oregon
PW Palau
PA Pennsylvania
PR Puerto Rico
RI Rhode Island
SC South Carolina
SD South Dakota
TN Tennessee
TX Texas
UT Utah
VT Vermont
VI Virgin Islands
VA Virginia
WA Washington
WV West Virginia
WI Wisconsin
WY Wyoming
ZIP/Postal Code
County:
King
Snohomish
Other (please specify)
Email Address:
Phone Number:
Homeless?
Yes
No
All information is confidential
What is your birth country?
Race/ Ethnicity:
Are you Spanish/Hispanic/Latino?
Yes
No
Are you an immigrant or refugee or new arrival to the U.S.?
Yes
No
Have you ever served on active duty in the U.S. military (inc. Natl. Guard/Reserves)?
Yes
No
Are you a spouse or partner of a US military person?
Yes
No
Language(s) spoken at home:
English
Spanish
Other (please specify)
Are you non-English speaking or of limited English ability?
Yes
No
Do you have a special need/disability?
Yes
No
Are you a parent, family member or caregiver of a child with a special need/disability?
Yes
No
Children:
Number of children (UNDER 18) living in your household:
Please check the age of each child in household:
0-11 months
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15+
Child 1:
0-11 months
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15+
Child 2:
0-11 months
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15+
Child 3:
0-11 months
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15+
Child 4:
0-11 months
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15+
Child 5:
0-11 months
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15+
Child 6:
0-11 months
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15+
Child 7:
0-11 months
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15+
Child 8:
0-11 months
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15+
TOTAL number of ALL people living in your household:
1
2
3
4
5
6
7
8+
Current Progress,
0 of 29 answered
