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 dwatkins@brhd.org OK Question Title * 1. Please fill out the following information. Name Address City/Town State/Province ZIP/Postal Code Email Address OK Question Title * 2. What is your gender? Female Male Other (specify) OK Question Title * 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) OK Question Title * 4. What is your age OK Question Title * 5. How old are your children? 3-11 12-18 I have children in both age ranges OK Question Title * 6. How did you hear about the parenting program? OK DONE