Co-Parenting & Divorce Class Registration Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Phone*Secondary PhoneEmail* Date you wish to attend*Saturday, August 29th, 9:30 am - 1:30 pmThursday, September 12th, 4:30 pm - 8:30 pmSaturday, September 21st, 9:30 am - 1:30 pmThursday, September 26th, 4:30 pm - 8:30 pmFormer 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?*YesNoI 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 InformationCo-Parenting and Divorce ClassBilling Address* Same as address entered above Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Credit Card* DiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20192020202120222023202420252026202720282029203020312032203320342035203620372038 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.
