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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

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