3995 East Market Street
York, PA 17402-2773
Phone: (717) 757-1227
Fax: (717) 757-1353

PRE-REGISTRATION FOR PARENTING GROUPS
Please complete and press the submit button only once.

Fields with * must be filled in for your registration to be processed.

Today's Date:   mm-dd-yyyy

 First RegistrantSecond Registrant
1. Name*:
2. Relationship to child(ren):
     (mother, father, grandparent, etc.)
3. If you are not the biological parent(s), are you the primary caregiver for the child(ren)?  Yes No
4. Address*:
    City, State, Zip*:
5. E-mail Address*:
(We encourage parents to list their email address in order to more easily communicate with the coordinator.)
6. Home Phone #*:
7. Work Phone #:
8. Are you a York County resident?*  Yes No
(If you do not reside in York County, please contact us at (717) 757-1227 for registration details.)


9. Child(ren) Information: (please complete ALL information below)*

Children's Name
(First)  (Middle)  (Last)
Date of Birth
(must have mm/dd/yyyy)
Child care Needed?
Y/N

10. Does your child have any special needs for child care? 

Child care is available. The cost of child care for each class is:
1 Child = $2.00   2 Children = $3.00   3 Children = $4.00   4 Children = $5.00

11. Group that you plan to attend:
  Location*:
 Class Date*:
  Time*:

12. How did you find out about our agency?
Referred By:
Caseworker's name (if applicable):

13. Is your attendance court-ordered? Yes No


**Family-Child Resources will be contacting**
registered parents for additional registration information if necessary.