Family-Child Resources, Inc. York, PA - Recognized Nationally, Statewide, and Locally for our client-focused services

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

The Kids' Group Coordinator will contact you soon to set up a screening appointment for your child and answer any questions you may have regarding this program.

Please use the form below to pre-register for Kids' Groups.

Mother's Name:

Father's Name:

Child's Name:

Male Female

Child's Date of Birth:

My child's race is: (optional - used for statistical purposes only)

African American

Asian

Caucasian

Hispanic

Other

Address:

(line 2 of address):

City, State, Zip:

E-mail Address:

Daytime Phone:

Evening Phone:

My child is experiencing/dealing with: (check all that apply)

divorce/separation

substance abuse

death

sexual or physical abuse

low self-esteem

getting along with others

Other: (please explain)

Group that your child plans to attend:
	Location:
	Class Date:
	Time:

Thank you for your interest in Kids' Groups.

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