HR Single Registration

Class: Date:

Participant First Name: Middle: Last:
I will be at least 18 years of age on the day of the class. Please list date of birth:
Primary Phone: OK for us to leave you a message?		Alternate Phone: OK for us to leave you a message?
Mailing Address: City: State: Zip code:
Email Address:
How did you hear about this class?		Please list any accomodations you may need:
Eligibility - Check all that apply:
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:
Ages of 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?
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 Richard Johnson (906-2759 or rjohnson@cr-sdc.org), Kristin Mauk (906-2762 or kmauk@cr-sdc.org), Tondalayo Davis (906-2728 or tdavis1@cr-sdc.org), or your SDC Family Advocate.

Thank you for registering for a Healthy Marriage class! Someone from the SDC Healthy Marriage team will follow up with you regarding your registration. If you have any questions please contact Kristen Mauk at 414.906.2762.

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

HR Single Registration

Making a difference today, while investing in tomorrow