Home
About Us
Community Resources
Contact Us

Juvenile Offenders
- Monitoring Programs
- Classes and Other Services
Parent Support
Teen Pregnancy Prevention
- Just for Teens/ Tweens
- Talking Tips for Parents
Truancy Prevention

Parent Class Registration Form

If you are interested in taking a parenting class, please complete the form below and someone from the Office on Youth will contact you. When staff contact you they will let you know:

when the class is starting,
where the class will be taught (or if it will offered online),
how to pick-up class materials,
make arrangements for you to pay the appropriate fee, and
answer all your questions.

We appreciate your interest and will be honored to help you.

Δ

Which class are you registering for?

24/7 Dad

Active Parenting

Loving Solutions

Parent Project

For Kids Sake

Participant Information

First Name

Last Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Cell phone number

Are you willing to receive text messages?

Yes

No

Email

Home or alternative phone number

Family Information

How many people are in your household?

Spouse's name (if applicable)

Will your spouse be taking the class with you?

Yes

No

Name of co-parent (if applicable)

Is there a protective order in place?

Yes

No

Please list the name and age of all your children under the age of 18.

Childcare Information

Is childcare necessary for you to participate in this class?

Yes

No

Please list the name of all children who will need childcare.

Please list special needs/ allergies of any child needing childcare

Emergency Contact Information (must be local)

First Name

Last Name

Emergency Contact cell phone number

Emergency Contact home or alternative phone number

Emergency Contact's relationship to you

Referral Information

Some description about this section

Who referred you to this class?

Courts

FAPT/ DSS

Lawyer

Family Counselor

Other referral

Yourself

Name of court

Name of caseworker

Name of lawyer

Name of counselor

Name of other referral

Is a letter of registration needed for your referral source?

Yes

No

Upcoming court date (if applicable)

Textarea

Waynesboro Office

Rosenwald Community Center
413 Port Republic Road
Waynesboro, VA 22980
Phone: 540-942-6757
Fax: 540-942-6785

Staunton Office

Nelson Street Teen Center
900 Nelson Street
Staunton, VA 24401
Phone: 540-332-3806
Fax: 540-332-3705

Search

Search for:

© Central Shenandoah Office on Youth (2022)