HR Couples Registration

Class Session: Date:

Partner 1 First Name: Middle: Last Name: I will be at least 18 years of age on the day of class:	Partner 2 First Name: Middle: Last Name: I will be at least 18 years of age on the day of class:
Address: City: State: Zip:	Address: City: State: Zip:
Phone: OK for us to leave you a message?	Phone: OK for us to leave you a message?
Email:	Email:
Eligibility Check all that apply for at least one partner:
I am a current Head Start parent.	Please list agency and site:
I am (or my partner is) pregnant and/or at least one of us has a child aged 0-5.
I meet the income guideline at the 100% level. (See chart below)
I meet the income guideline at the 130% level. (See chart below)
I am unemployed.

I do not meet any of the above requirements but I am attending with someone who does. His/Her name is:
Agesof children who live with you and who you have legal custody of (Check all that apply): 0-2 3-5 6-9 10-12 13-17	If you have a child age 5 or younger you may qualify for Head Start or Early Head Start. Would you like someone to contact you about these programs?
How did you hear about this class?	Please list any accommodations either of you may need:
Important Information: Classes are offered to adults (age 18 or above) only. Please secure childcare for your children if needed. Each class consists of 8 hours of training. Please plan on attending the session in its entirety. A complete registration form, pre-assessment, post-assessment, and class evaluation may be given the day of the class. This information is confidential and someone can assist you with its completion if you would like. Please direct any questions regarding this class to Kristin Mauk (906-2762), Tondalayo Davis (906-2728), Richard Johnson (906-2759), or your SDC Family Advocate

Thank you for registering for a Healthy Marriage class! Someone from the Healthy Marriage team will get back to your shortly about this registration. Should you have any questions about this or any other class please contact Kristen Mauk at 414.906.2762.

Remember: The Marriage that you save may be your own!

HR Couples Registration

Making a difference today, while investing in tomorrow