RIGHT FROM THE START REGISTRATION FORM 5 February – 19 March 2015 (Thursdays 9:30am – 11:30am) Central Gateway for Families, Chilliwack Central Elementary Community School Society 9435 Young Road, Chilliwack
Name(s): _________________________________________________________________ Home Address: _________________________________________________________________ Home Telephone: ________________________ Cell Phone: _____________________ Children: Name: _________________ _________________ _________________ _________________
Age: ___________________ ___________________ ___________________ ___________________
Gender: _________ _________ _________ _________
Family Composition: ________________________________________________________________________________ ________________________________________________________________________________ Do any of your children have extra support needs? ________________________________________________________________________________ ________________________________________________________________________________ Are you/have you received any services from other service providers ? ________________________________________________________________________________ ________________________________________________________________________________ Have you attended any other Parenting Courses? If so, please describe: ________________________________________________________________________________ ________________________________________________________________________________ What are your goals for this program – what would you like to learn during this group (Particular topics)? ________________________________________________________________________________ ________________________________________________________________________________ How did you find out about our program? _____________________________________________