New Parent Education Course Registration

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Age (Optional)

Gender Identification (optional)

Answer "none" if not applicable

Sexual Orientation (optional)

Marital Status (optional)

What would you most like to gain from attending this course? *

Optional Donation

This course is free to all participants, but donations are welcome with all proceeds going back into the program.

Photo and Video Release *

I acknowledge that photos and videos from this program can and will be used for informational and advertising materials. The use of photos and videos may include, but is not limited to, social media posts, posts on the organization's website, digital advertisements, news stories, and paper advertisements.

Signature

Clear Signature

Address: 2450 Summers Lane

Klamath Falls, OR 97603

Phone: (541) 887-2207

Fax: (541) 887-2208

Email: Info@tatertotstherapy.org

Fall 2023 New Parent Education Registration