Co-Parenting & Divorce Form

Co-Parenting & Divorce Class Registration

Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Primary Phone*
Secondary Phone
Email*
Date you wish to attend*
Former Spouse*
First Last
Case #*
Judge's Name*
First Last
Attorney's Name*
First Last
Has a Victim's Protection Order (VPO) been issued on either party?*
- Yes
- No
I would also like information on the following services: (Please check all that apply)
- Parenting Programs
- Domestic Violence
- Family Counseling
- Anger Management
- Grief counseling
- Substance Abuse Treatment
- Al-Anon
- Other
Someone from our office will contact you about these services.
If 'other', please specify:
Payment Information
Co-Parenting and Divorce Class
Billing Address*
Same as address entered above

Street Address Address Line 2 City State ZIP Code
Credit Card*

Discover
MasterCard
Visa
Supported Credit Cards: Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Total
$0.00
*
- I have read and agree to the information below
- * Click on Register and Pay Now only ONCE to submit your information and payment.
- * Payment for seminar is non-refundable.
- * A $10 administration fee will be charged to reschedule.
- * Family Builders does not provide child care, nor will children be permitted to attend the seminar.
- * Couples are not permitted to attend the same class.
- * Must present a photo ID for admittance on day of class.