Parenting Wisely Registration Form

Login information

Once we receive your information we will send you your login information to the email you provided.

For questions please contact:

djones@brhd.org

cseifert@brhd.org

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* 1. Please fill out the following information.

First and Last Name

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

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* 2. What is your gender?

Female

Male

Other (specify)

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* 3. Which race/ethnicity best describes you? (Please choose only one.)

American Indian or Alaskan Native

Asian / Pacific Islander

Black or African American

Hispanic

White / Caucasian

Multiple ethnicity / Other (please specify)

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* 4. What language would you prefer to use for the program?

English

Spanish

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* 5. What is your age

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* 6. How old are your children?

3-11

12-18

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* 7. I have children in both age ranges and would like to start with the

3-11 Young Edition

12-18 Teen Edition

Parenting Wisely Registration Form

Login information

Question Title

* 1. Please fill out the following information.

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* 2. What is your gender?

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* 3. Which race/ethnicity best describes you? (Please choose only one.)

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* 4. What language would you prefer to use for the program?

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* 5. What is your age

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* 6. How old are your children?

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* 7. I have children in both age ranges and would like to start with the

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* 8. How did you hear about the parenting program?