Please complete this registration request for an upcoming Empact Basics program. Requests will be reviewed and confirmed by the hosts. Approved requests will be registered to participate in the program. 
If you want to learn more about what our programs do for families, please watch this video.

All information collected is considered confidential and will only be used for the purposes of communicating with you about Empact Parenting programs. Your information will not be sold or used for any other purposes.
Thank you! 
Empact Parenting Programs - 
  • Explore and discuss parenting styles, knowledge, beliefs, and behaviors
  • Teach proven communication and behavior management parenting tools
  • Help parents plan for the future
  • Encourage personal awareness
  • Improve family health, viability, engagement, and interactions
  • Connect parents with other parents

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* 1. Please provide current and accurate contact information. We need a valid street mailing address that can receive the parent program kits and materials. Your email address will receive regular communications about the program. And, we may need your phone numbers to provide technical support during the weekly Zoom sessions.

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* 2. Yes/No: I have a child or teen with a bleeding disorder.

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* 3. Please enter the name of your HTC

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* 4. What is the age of your child or teen with the bleeding disorder?

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* 5. How did you hear about this Empact Parenting program? (check all that apply)

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* 6. Why do you want to attend this Empact Parenting program?

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* 7. Which race/ethnicity best describes you and your child? (Please choose only one.)

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* 8. Please select your preferred language for your program workbook and materials

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* 9. How many parents/caregivers will be attending this program? (please enter a number)

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* 10. Yes/No:  I understand that this is a virtual Empact Parenting program will take place over five weeks. I will be required to watch videos and complete exercises on my own AND participate in weekly parent-to-parent zoom sessions.

Once you click Submit, you have submitted your program registration request. We will process all of the requests as quickly as we can. If need to get in touch with us before the start of the program, please contact us at info@eeminds.org. Thank you!

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