Family Life Education Class Registration

Register for this event

Event Location

Event Time / Details

Email*

Number of Adults Attending?*

Adult 1 Name*

First Last

Adult 1 Age*

Adult 1 Gender

Male
Female

Adult 1 Race/Ethnicity

Adult 2 Name*

First Last

Adult 2 Age*

Adult 2 Gender

Male
Female

Adult 2 Race/Ethnicity

How many children do you have?*

Please choose the number of children, provide their names and ages.

Child 1 Info

First Name Last Name Age

Child 2 Info

First Name Last Name Age

Child 3 Info

First Name Last Name Age

Child 4 Info

First Name Last Name Age

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Who referred you to COBYS?*

Lancaster County Children & Youth
Parole/Probation Office
Juvenile Probation
School

Name of Caseworker or person who referred you:*

Comments

Consent*

I agree and authorize the information below.

By submitting this registration I authorize and agree to the following:
I authorize COBYS Family Services to provide demographic information (i.e. race, age, etc.) to funding sources and release attendance and/or participation information upon request to the funding source and the participant’s referral source.
I agree and understand COBYS Family Services provides educators. Therefore, I will not ask anyone from COBYS to be called for testimony for any future proceedings. COBYS will acknowledge attendance to classes but no other information.
I understand that COBYS staff are mandated reporters, and are required by law to report to the appropriate agency when there is reasonable cause to suspect child abuse.

Family Life Education Class Registration

Event Registration

The Oregon Counseling Center

The Palmyra Area Counseling Center