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Catholic Charities, Diocese of Norwich Parenting Education Program
Intake Date:
Docket Number:
Rockville-Tolland Judicial District
Class Date:
Willimantic-Windham Judicial District
Middletown- Middlesex Judicial District
New London-New London Judicial District
Norwich-New London Judicial District Name:
Home Phone #
Address:
Cell Phone #
City:
State:
Work Phone #
Zip Code:
E-mail:
Best Time Or Number To Call :
Referred By:
Court
Court Status:
Divorced Pending
Lawyer
Other
Custody
Visitation
Other
Which Court Are You Using? Ages Of Children: English
Primary Language: Yes No
Do You Have Any Safety Concerns?
How Can We Best Accommodate You?
Yes No
Other
Explain: (Limited to Four Lines )
Yes No
Is There Any One You Would Not Like To Be In The Same Class With? Do You Have Any Special Need?
Spanish
If Yes Is That The Other Parent?
What Are They:
Persons Name
Yes No
Vision Impaired
Hearing Impaired
Learning Disabled
Physically Disabled
(Limited to Four Lines )
Mail Your Registration Form along with a JD-FM-149 Form (Parent Ed. Cert. & Results), $125.00 Payment, or Fee Waiver (Original signed by the court) TO: Catholic Charities Diocese Of Norwich, 331 Main Street, Norwich, CT. 06360 Acceptable forms of payment: Cash if you come in to the Norwich Office (No Personal Checks) / Mail In a Money Order made out to Catholic Charities, Diocese Of Norwich We also accept Credit/Debit Visa, MasterCard, Discover WE MUST RECEIVE FORMS /PAYMENTS DATED A WEEK BEFORE THE CLASS. QUESTIONS: Please Call 860-889-8346 ext. 263
Do You Have A Waiver From The Court For Fees? Cash
Payment Method:
Yes
Master Card
Card # Rescheduled?
(Must Be Signed By Court Clerk)
Money Order Visa
Credit Card By Phone:
No
Credit Card Discover
Exp Date: Yes No
Date Paid
Original Date Catholic Charities, Diocese Of Norwich 2013
Authorization # Rescheduled Date